Human Sexuality Nodrm

“An awesome examination of human sexuality, encompassing biological,
social, psychological, cultural, and global perspectives. The book’s compre-

hensive scope captures every aspect of human sexuality from its mammalian
beginnings, including human physiology, sexual practices, sex and gender
identities, its relation to kinship, marriage and the life cycle, sexually trans-
mitted diseases, and contemporary factors such as reproductive technology,
internet pornography, and sexual violence. The authors explore various con-
troversies regarding sexuality, providing balanced judgements based on aca-
demic research in industrial and nonindustrial societies. A Must Read!”
— Serena Nanda, Professor Emeritus, Anthropology,
City University of New York; author of Gender Diversity:
Crosscultural Comparisons and Love and Marriage:
Cultural Diversity in a Changing World
“This collaborative volume updates the team’s popular textbook covering top-
ics from A-frame orgasm to zygote transplantation. Most sexuality textbooks
focus primarily on biological or psychological aspects. In contrast, this book
truly presents a holistic overview of human sexuality in its social contexts and
cross-cultural variability, attending as well to variations in sexual orientation
and gender diversity, while clearly explaining the physiology and psychology.
Ideal for anthropology of sexuality courses, the clear descriptions of anthro-
pological and sociological concepts also suit this book for a general sexuality
course or as a general reference.”
— Timothy M. Hall, MD PhD, Assistant Clinical
Professor, UCLA Dept. of Family Medicine
Taylor & Francis
Taylor & Francis Group
http://taylorandfrancis.com
Human Sexuality
This groundbreaking second edition of Human Sexuality continues its broad

and interdisciplinary goal of providing readers with a comprehensive overview
on sexuality as a core part of our individual identities and social lives.
Edited by anthropological experts on the subject, this unique textbook
integrates evolutionary and cultural aspects to provide a fully interdisciplinary
approach to human sexuality that is rare in this area of scholarship. Fully
updated throughout in line with developments in the field, this second edition
includes fresh material exploring new sexual identities, sexual violence and
consent, Internet pornography, conversion therapy, polyamory, and much
more. In addition to providing a rich array of photographs, illustrations, tables,
and a glossary of terms, this textbook explores:
• pregnancy and childbirth as a bio-cultural experience

• life-course issues related to gender identity, sexual orientations, behaviors,
and lifestyles
• socioeconomic, political, historical, and ecological influences on sexual
behavior
• early childhood sexuality, puberty, and adolescence
• birth control, fertility, conception, and sexual differentiation
• HIV infection, AIDS, AIDS globalization, and sex work.
Utilizing viewpoints across cultural and national boundaries and taking into
account the evolution of human anatomy, sexual behavior, attitudes, and
beliefs across the globe, Human Sexuality, Second Edition, remains an essential
text for educators and students who wish to understand human sexuality in all
of its richness and complexity.
Anne Bolin, PhD, is a Professor Emerita from Elon University, diplomate with
the American Board of Sexology, a certified sex researcher, and former co-chair/
co-founder of the Human Sexuality and Anthropology Interest Group.
Patricia Whelehan, PhD, CST, CAC-CA, NY, is a Professor Emerita from

SUNY Potsdam, a certified HIV Test Counselor in California and New York,
and a certified sex therapist, mentor, diplomate, and clinical supervisor with
the American Board of Sexology.
Muriel Vernon, PhD, is an Assistant Professor of anthropology from Elon
University. She is the founder of followthefuture.org and currently specializes
in cellular agriculture education.
Katja Antoine, PhD, is Program and Research Developer at the UCLA Center
for the Study of Women.
Human Sexuality
Biological, Psychological, and
Cultural Perspectives
Second Edition
Anne Bolin, Patricia Whelehan,

Muriel Vernon, and Katja Antoine
Second edition published 2021
by Routledge
52 Vanderbilt Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2021 Anne Bolin, Patricia Whelehan, Muriel Vernon, and Katja Antoine
The right of Anne Bolin, Patricia Whelehan, Muriel Vernon, and Katja Antoine
to be identified as authors of this work has been asserted by them in accordance
with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic, mechanical,
or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
First edition published by Routledge 2009
Library of Congress Cataloging-in-Publication Data
Names: Bolin, Anne, author. | Whelehan, Patricia, author. |
Vernon, Muriel, author. | Antoine, Katja, author.
Title: Human sexuality: biological, psychological, and
cultural perspectives / Anne Bolin, Patricia Whelehan,
Muriel Vernon, and Katja Antoine.
Description: Second edition. | New York, NY: Routledge, 2021. |
Includes bibliographical references and index. | .
Identifiers: LCCN 2020044454 (print) | LCCN 2020044455 (ebook) |
ISBN 9780367219796 (hardback) | ISBN 9780367219789 (paperback) |
ISBN 9780429269158 (ebook)
Subjects: LCSH: Sex. | Sex customs. | Sex (Biology) | Sexual health.
Classification: LCC GN484.3 .B64 2021 (print) |
LCC GN484.3 (ebook) | DDC 306.7—dc23
LC record available at https://lccn.loc.gov/2020044454
LC ebook record available at https://lccn.loc.gov/2020044455
ISBN: 978-0-367–21979-6 (hbk)

ISBN: 978-0-367–21978-9 (pbk)
ISBN: 978-0-429–26915-8 (ebk)
Typeset in Goudy
by codeMantra
Contents
List of Illustrations xiii

List of Tables xiv
List of Box xv
About the Authors xvi
About the Contributors xviii
Preface xix
Acknowledgments xxii
1 Introduction 1
Chapter Overview 1
The Anthropological Perspective 1
Summary 18
Thought-Provoking Questions 19
Suggested Resources 19
2 Biological, Psychological, and Cultural Approaches 20

GE O RGI NA S. H A M MO C K
Chapter Overview 20
Anthropological Perspectives in Contrast 20
Definitions of Human Sexuality 30
Biological Definitions and Dimensions 33
Sexual Violence 41
Summary 45
3 The Evolutionary History of Human Sexuality 47

W E N DA R . T R E VAT H A N
Chapter Overview 47
Arboreal and Terrestrial Adaptations 51
viii Contents
Evolution of the Brain 54
Evolution of the Human Family 55
Evolution of Intimacy 60
Female Sexuality 61
Human Evolution: A Synthesis 65
Summary 66
4 Introduction to the Hormonal Basis of Modern

Human Sexuality 68
Chapter Overview 68
Definitions of Auxiliary Terms and Concepts 69
Summary 78
5 Modern Human Male Anatomy and Physiology 80

Chapter Overview 80
Secondary Sex Characteristics 81
Primary Sex Characteristics 85
Summary 93
6 Modern Human Female Anatomy and Physiology 95

Chapter Overview 95
Secondary Sex Characteristics 97
Primary Sex Characteristics 100
Menstrual Cycle 112
Reproductive Technology 120
Summary 122
7 Fertility, Conception, and Sexual Differentiation 124

Chapter Overview 124
Fertility and Infertility 124
Conception 131
Intersexuality 134
Summary 137
Contents ix
8 Birth Control, Abortion, and Methods of Birth Control in
Cross-Cultural Contexts 138
Birth Control: Practices and Prevalence in Industrialized and
Nonindustrialized Nations 138
Abortion 164
Traditional Methods of Birth Control in Cross-Cultural
Context 176
Summary 186
9 Pregnancy and Childbirth 188

The Fetus 189
The Pregnant Female 190
Birthing Models 194
Postpartum 198
Summary 200
10 Sexuality through the Life Stages, Part I: Early Childhood

Sexuality 201
Definitions 201
Incest Taboos 211
Theories of Childhood Sexuality 223
Cultural Relativism and Childhood Sexual Behavior 224
Summary 229
11 Sexuality through the Life Stages, Part II: Puberty and

Adolescence 231
Puberty and Adolescence: A Bio-Cultural Phenomenon 231
Puberty Rituals: Initiation Ceremonies as Rites of Passage 236
Female Genital Cutting 240
Male Insemination Rites 245
Adolescent Sexual Behavior in NonIndustrialized Countries 248
Adolescent Sexual Behavior in Industrialized Countries 255
Adolescent Fertility and Sterility 265
x Contents
Sex Education in the United States 268
Comparison and Contrast: Preparation for and
Transition to Adulthood 273
Summary 276
12 Sexuality through the Life Stages, Part III: Adult Sexuality 279
Experiencing Sexuality and Human Sexual Response (HSR) 279
The Cross-Cultural Spectrum: Indigenous and NonIndustrialized
Sexuality 280
Theories of Sexology in Industrialized Society 286
Overview of US Sexual Attitudes 299
Problems in Sexual Response: Diagnosis and Disagreements 300
Hookup Culture 312
Sex and Social Media 315
Parenting Styles 316
Summary 319
13 Sexuality through the Life Stages, Part IV: Sexuality

and Aging 321
Sexuality and Aging 321
Aging Men in the United States 325
Aging Women in the United States 329
Hormone Replacement Therapy/Menopausal Hormone
Treatment (MHT) 331
Biological, Psychological, and Cultural Perspectives on Menopause 334
Cross-Cultural Ideologies of Aging 340
Summary 346
14 Sexual Identities, Preferences, and Behaviors 348

Sexual Identities 348
Causes of Sexual Orientation 350
Summary 362
Contents xi
15 Sex, Sexuality, and Gender 364

Gender Identities and Gender Roles 364
Transgender People 365
Gender Variance: Cross-Cultural Gender Diversity 374
Cross-Cultural Gender Roles: Traditions and Changes 385
Summary 387
16 Sexual Health: HIV, AIDS, and Sexually

Transmitted Diseases 389
Introduction 389
Sexually Transmitted Diseases 395
Epidemiology of HIV/AIDS 395
Modes of Transmission and Co-Factors 401
Biomedical Aspects of HIV/AIDS 402
HIV Testing 405
Sex and HIV/AIDS 409
Drugs, Needles, and HIV/AIDS 410
Women and HIV/AIDS 413
Political and Economic Dimensions of HIV/AIDS 414
Summary 418
17 Global Aspects of Sex and Sexuality 420

Globalization 420
Globalization and Sexuality: Trafficking 422
Sex Work 423
Sex Work in Industrialized Societies 425
Sex Work in NonIndustrialized Societies 427
Globalization, Sex Work, and HIV/AIDS 432
Summary 438
xii Contents
18 Summary and Conclusion 440
Notes 445
Glossary 449
References 480
Index 555
Illustrations
1.1 The individual in society 3

1.2 Culture as architecture 15
3.1 The place of humans in the biological taxonomy of
living organisms 49
3.2 How natural selection works on traits 50
4.1 Female reproductive system 70
4.2 Venn diagram: sexual cycle/reproductive cycle 72
4.3 H-P-G axis graphics for female 74
4.4 H-P-G axis graphics for male 75
5.1 Penis—with and without foreskin 86
5.2 Male internal reproductive sexual anatomy 86
6.1 Range of female breasts from the adolescent period 99
6.2 Vulva: external anterior and internal anteriolateral view 101
6.3 Clitoral hood and clitoris 102
6.4 Female reproductive system: drawing of the internal sexual
anatomy 110
6.5 Menstrual cycle diagrammatically 115
7.1 Complete diagram of a human spermatozoa 126
9.1 Embryo seven weeks after conception 189
9.2 Stages of childbirth 192
9.3 Thirty-minute-old infant 193
10.1 Kinship variations 208
11.1 Percentage of high school students who ever had sex from
2007–2017 259
11.2 Methods of contraception ever used among females aged
15–19 who had ever had sexual intercourse 261
11.3 Trends in the prevalence of sexual behaviors and HIV
testing, CDC. 262
11.4 Percentage of high school students who used a condom the
last time they had sex 264
11.5 Birth rates per 1,000 females ages 15–19, by race and
Hispanic origin of mother, 1990–2017 267
Tables
4.1 Comparative anatomy 73

4.2 Hormones involved in H-P-G axis functioning 77
7.1 Summary of anomalies of prenatal differentiation 136
8.1 Contraceptive methods among married and in-union
women ages 15–49 by world region, percentage of
population, and type 143
8.2 Health and economic indicators in countries with a high
unmet need for family planning 154
8.3 Laws and abortion policies by state as of November 2019 169
8.4 Reported abortions, by known weeks of gestation, age group,
race, and ethnicity of women who obtained abortions—
selected reporting areas, United States, 2015 172
8.5 Examples of legal trends in international abortion 173
16.1 Common sexually transmitted infections (STIs) and
sexually transmitted diseases (STDs): mode of transmission,
symptoms, and treatment 391
16.2 Regional/global HIV/AIDS statistics 396
16.3 United States HIV/AIDS statistics 2017 397
16.4 AIDS cases by age 397
16.5 Simple comparison of men and women living with HIV/
AIDS in 2016 398
16.6 HIV tests: amount of time needed for accuracy, detection of
HIV/AIDS 403
17.1 Sexual tourism 430
Box
8.1 Birth control methods guide 144

About the Authors
Anne Bolin is an Emerita Professor of Anthropology

at Elon University, Elon, North Carolina. Her book,
In Search of Eve: Transsexual Rites of Passage (Bergin
and Garvey), received a CHOICE Magazine Award
for an Outstanding Academic Book for 1988–1989.
With co-author, Patricia Whelehan, she has pub-
lished Perspectives on Human Sexuality (State Univer-
sity of New York Press, 1999.) In 2003, she authored
Athletic Intruders: Women, Culture and Exercise, with
Jane Granskog (State University of New York Press).
With co-author Patricia Whelehan, she published the
first edition of Human Sexuality: Biological, Psychological and Cultural
Perspectives, (Routledge/Taylor and Francis, 2009). Along with Patricia
Whelehan, she was a senior editor of The International Encyclopedia of
Sexuality, (Malden, Oxford: Wiley-Blackwell 2015). She has been a
Diplomate with the American Board of Sexology, a certified sex re-
searcher, Fellow of the Society for Applied Anthropology, former co-
chair/co-founder of the Human Sexuality and Anthropology Interest
Group. She is the recipient of the Elon University Distinguished Scholar
Award and the Elon Medallion for Meritorious Service and Loyalty.
Patricia Whelehan is a Professor Emerita of Anthropol-
ogy and was the campuses’ AIDS Education Coordina-
tor at SUNY-Potsdam. She is the editor of Women and
Health: Cross-Cultural Perspectives (Bergin and Garvey/
Greenwood Publishers, 1988), co-author of Perspectives
on Human Sexuality with Anne Bolin (SUNY-Press,
1999) and Human Sexuality: Biological, Psychological and
Cultural Perspectives (Routledge/Taylor and Francis,
2009); and author of An Anthropological Perspective on
Prostitution: The World’s Oldest Profession (Edwin Mel-
len Press, 2001). Her textbook, The Anthropology of
AIDS: A Global Perspective (University Press of Florida) was published in
2009. She and Dr. Anne Bolin were senior co-editors of the International
Encyclopedia of Human Sexuality (Malden, Oxford: Wiley-Blackwell, 2015)
About the Authors xvii
In 2007, she received the President’s Award for Excellence in Service.
In 1999 and 2008, she received the Phi Eta Sigma award for Outstanding
Teacher of the year, and in 2008 she was inducted into Phi Kappa Phi, a
national honor’s society that recognizes scholarly distinction. In 2018, she
was awarded The Moher Downing Distinguished Service Award, AARG,
Section of SMA.
Muriel Vernon received her PhD in Anthropology from
the University of California Los Angeles. She is an As-
sistant Professor of Anthropology in the Department of
Sociology and Anthropology at Elon University in Elon,
North Carolina. She has conducted research on trans-
gender health and MSM demographics.
Katja Antoine received her PhD in Anthropology from

the University of California Los Angeles. Her research
centers on issues of racism and sexism in the US enter-
tainment industry and pop-culture discourse. She is
Program and Research Developer at the UCLA Center
for the Study of Women.
About the Contributors
Georgina S. Hammock is a social psychologist who specializes in the study of

violence. She received her doctorate from the University of Georgia. Since
that time she has studied violence between strangers, violence between
intimates, conflict in intimate relationships, and the perception of violent
encounters. She has published and presented this work both nationally and
internationally. Most recently she has focused on the study of intimate vi-
olence with a concentration in the new area of psychological aggression.
Her work in this area can be found in the journals Violence and Victims,
Aggression and Violent Behavior; Aggressive Behavior, Journal of Applied So-
cial Psychology, and the International Review of Social Psychology. She also
worked recently with her colleague, Deborah Richardson, to edit a special
issue on non-direct aggression for the International Review of Social Psychol-
ogy. Presently, she is an Assistant Professor at Augusta State University.
Wenda R. Trevathan is Regents Professor of Anthropology at New Mexico State
University, where she has been on the faculty since 1983. She received her
PhD in anthropology from the University of Colorado and is a biological an-
thropologist whose research focuses on the evolutionary and biocultural fac-
tors underlying human reproduction including childbirth, maternal behavior,
sexuality, and menopause. She is the recipient of the Margaret Mead Award
from the American Anthropological Association and the Society for Applied
Anthropology (1990) and is the author of Human Birth: An Evolutionary Per-
spective (1987). She also publishes in the area of evolutionary medicine, most
significantly the two edited books (with E. O. Smith and J. J. McKenna) Evolu-
tionary Medicine (1999) and Evolutionary Medicine and Health: New Perspectives
(2007), published by Oxford University Press. She is a co-author on a series of
textbooks in physical anthropology published by Wadsworth Press (Jurmain
et al.). Awards she has received include the New Mexico Professor of the
Year, awarded by the Carnegie Foundation for the Advancement of Teaching
(1994), the Westhafer Award for Excellence in Research at New Mexico State
University (1998), and the Donald C. Roush Excellence in Teaching Award,
also from New Mexico State University (1999). She was a Fulbright Senior
Scholar to the University of San Carlos in the Philippines in 1999–2000. Her
current research includes cortisol in mother-infant interaction and stress, sex-
uality, and mood during the menopause transition.
Preface
This preface is a welcome to all our potential readers—students, professors,

and researchers—of human sexuality. For those of you who teach or conduct
research in human sexuality, you may be wondering why there is the need for
yet another undergraduate human sexuality text, especially since there are sev-
eral fine books on the market dealing with US sexual behavior and attitudes.
We believe that since most of the current undergraduate texts are not writ-
ten by anthropologists, there are dimensions of human sexuality that are
not covered by these. Most noticeably, Human Sexuality: Biological, Psycho-
logical, and Cultural Perspectives does not focus on a view of sexuality as an-
chored in Euro-American behaviors; nor do we wish to inculcate a view of
nonindustrialized peoples as “exotic others.” Euro-American behaviors and
beliefs are as exotic and alien to people in other cultures as theirs are to us,
or even to people of previous generations in our own culture, as their behav-
iors are to us. This book incorporates an anthropological perspective that is
unique and different from most of the available literature. For those unfamiliar
with anthropology, this perspective is intrinsically an interdisciplinary one
emphasizing the intersections of biological, psychological, and cultural aspects
of human sexuality, hence the title. Specifically, Human Sexuality: Biological,
Psychological, and Cultural Perspectives integrates evolutionary, cross-cultural,
and bio-cultural dimensions of human sexuality. We examine patterns of sex-
uality as they occur in a variety of cultures, including our own, as opposed to
a conflict/issues approach of many late-twentieth century US sexuality texts.
Translated, this means that we look at modern human sexual behavior as
having evolved from a primate heritage. It has changed through time and
space physically and behaviorally as a means of adapting to our specific needs
as a large-brained, upright organism, which depends on learning as its primary
survival (adaptive) strategy. We compare ourselves to our nearest relatives—
the non-human primates—and to other human groups to gain a better un-
derstanding and insight into what we share as a human species, as well as
carryovers from our primate heritage. We integrate, as much as possible, the
biological and learned aspects of sexuality through the life cycle from concep-
tion through old age.
The twenty-first century brings us daunting challenges as a species, mem-
bers of groups, and as individuals. HIV infection and AIDS are global,
xx Preface
pandemic health concerns that governments and health agencies realize are
ongoing concerns. HIV infection cross-culturally and in the United States is
spread primarily through sexual contact. There is neither a cure nor a vac-
cine available in this, the fourth decade of the pandemic, although vaccine
trials continue and pre- and post-exposure prophylactics are now available to
many individuals. Thus, prevention of infection through education coupled
with behavior and attitude changes which are geared to the specific needs,
perceptions, and values of people at risk and groups seriously impacted by the
disease continue to be important. Interventions need to occur at the individ-
ual, societal, and global level. These necessitate a cross-cultural, holistic, and
relativistic anthropological approach.
We are a human community. Twenty-first century technology that includes
computers and satellite communication, as well as industrialized societies’
medical technology, which can be available on a worldwide basis, makes
diversity (i.e., a variety of value systems, behaviors, and perceptions) a real-
ity of United States and international life. To survive, we need to appreci-
ate, understand, and accept difference and use it to enhance our humanity
as individuals, groups, and a species. Meeting these challenges also involves
a cross-cultural, comparative anthropological perspective. Therefore, our ap-
proach in this book has both theoretical as well as applied dimensions in try-
ing to understand ourselves as sexual beings.
To do this, however, we have recognized certain limits to this text. One, we
do not cover every aspect of modern US sexuality. Two, this is not a book on
twenty-first century US sexual behavior. Although we include US sexuality as
part of human sexuality, we do not focus primarily on it. Simultaneously, we
include sexual behaviors and attitudes of nonindustrialized people through
time and space. We try to incorporate sexuality as part of their worldview and
socio-cultural life—as integrated and related to political, economic, and social
structures.
Those sexual behaviors and aspects of the life cycle that we discuss are those,
which are human (found in all human groups) although arranged, defined, and
constructed according to the specific demands of a given group. For example,
fertility issues, pregnancy, and childbirth are pan-human concerns. We discuss
how the United States and other societies culturally define and manage these
life cycle issues. Childhood sexuality is also part of human sexuality. So, we
examine how various cultures, including our own, channel and regard child-
hood sexuality as a prelude to adult sexuality. Transgender identities include
socio-sexual roles found cross-culturally and in the United States. They are
defined, structured, and responded to very differently in the United States
than in the nonindustrialized and international societies in which they occur.
On the other hand, fetishes and paraphilias (focusing exclusively on particu-
lar objects or body parts as the primary or only means of sexual arousal) appear
not to be particularly widespread cross-culturally. They are not dealt with in
this book. While they are not dealt with specifically, we do provide an import-
ant framework for furthering the understanding of such Euro-American-based
Preface xxi
categories, or “culture-bound” syndromes. We aim for a better understanding
of human sexuality—that which we share as a species and not exclusively what
occurs in middle-class US society.
Given this interdisciplinary perspective, instructors, researchers, and stu-
dents may use Human Sexuality in a variety of ways. It can be used as a basic
text with supplemental or recommended readings in US sexuality courses. Or,
it may be used as a supplemental text for those most comfortable in dealing
with human sexuality as it occurs in the United States in this relatively new
century. It can also serve as a resource for researchers and teachers who want
to incorporate evolutionary or cross-cultural data as part of their writing and
teaching.
We hope the approach taken here will be of use and value to you in your
understanding of this highly varied and data-rich topic of human sexuality. By
understanding human sexuality, we have a greater appreciation of and may be
able to develop a broader tolerance of the diversity that comprises our species.
One final caveat is in order that relates to the speed with which science
progresses. There is a necessary time lag in the publication of a manuscript,
so that when a book comes into print it cannot, by virtue of the production
process, contain the most recent findings in the months prior to its publication
date. Scientific research surges forward at a rapid rate in our postmodern world.
As a consequence, we would like our readers to be aware that new scientific ev-
idence and cultural developments will continue to occur as Human Sexuality:
Biological, Psychological, and Cultural Perspectives is published.
The second edition of the book includes the addition of two new authors.
Muriel Vernon, the new third author, and Katja Antoine, the new fourth au-
thor, updated and edited the 2009 edition to be slightly more concise and re-
organized some of the chapters in terms of topics. While chapters 1 through 6
remain relatively unchanged, chapters 7 through 9 cover the human reproduc-
tive cycle from fertility and conception to pregnancy and childbirth. Chapters
10 through 13 cover human sexuality through the life cycle from childhood to
old age. New topics include hookup culture and social media as well as sexual
harassment. Chapter 14 addresses sexual preferences, behaviors, and identi-
ties. Chapter 15 covers the relationship between sex, sexuality, and gender,
and includes transgender people. Chapter 16 addresses STIs and HIV/AIDS.
Chapter 17 focuses on Globalization and Sexuality. Chapter 18 includes a brief
summary and conclusion.
Acknowledgments
In this second edition of Human Sexuality: Biological, Psychological and Cultural

Perspectives, we honor those who worked with us on the first edition as a group.
These included our interns from our respective institutions, our university col-
leagues who offered substantial encouragement, the students in our anthro-
pology of human sexuality courses, as well as the institutional support Elon
University provided to Anne Bolin. Anne Bolin would like to thank Greg
Babcock, her spouse, high school sweetheart, and partner who has provided
her with an environment filled with love and harmony in which to work.
We want to thank Muriel Vernon and Katja Antoine for being willing to
revise, update, and improve this edition under the mentorship and editing
work of both Anne Bolin, Emerita Professor of Anthropology at Elon Uni-
versity, and Patricia Whelehan, Emerita Professor of Anthropology at SUNY-
Potsdam. We also want to thank the interns at Elon who worked with Muriel
and Katja in preparing chapters and associated materials for our review. And,
once again, Linda Martindale provided her excellent editing efforts and man-
uscript preparation. Textbooks are a massive undertaking and we are indebted
to all of you.
Muriel Vernon wants to thank Elon’s Faculty Research and Development
Committee for a course release to work on the second edition of this book.
I would also like to extend my appreciation to Linda Martindale who helped
us again in 2020 with the formatting of the manuscript for the second edi-
tion of the book. I am most grateful for Elon student research assistants who
have helped me immensely to find updated resources for the second edition
of the book. First, I would like to thank Morgan Maner who worked with me
after she graduated from Elon. Morgan Maner received her master’s degree
from King’s College London in Global Health and Social Justice where she
examined transgender people’s experiences of marginalization in primary care
clinics. Her research interests include trauma-informed care, health systems,
and minority health. Presently, she is studying medical sciences at Brown Uni-
versity with aspirations to attend medical school. Secondly, I would like to
thank two current Elon students, Caroline Snyder and Alexandra Mangan,
for taking on the revision of the chapter on STIs and HIV/AIDS under my
supervision. Caroline Snyder was born and raised in Atlanta Georgia and at-
tended Elon University in North Carolina. She majored in Biology and in
Acknowledgments xxiii
Public Health. In the future, she plans to pursue further education in the
field of genetic counseling and public health. Alexandra Mangan was born in
Chicago, raised in Vermont and attended Elon University in North Carolina.
She majored in Human Service Studies with minors in Psychology and Wom-
en’s Gender and Sexuality Studies. She spent a semester in Amsterdam, where
she conducted research on the use of fashion amongst the undocumented im-
migration population that identifies as LGBTQ+ and organized a fashion show
to convey her findings. In the future, she plans to pursue further education in
the field of global health. Lastly, I would like to thank Hannah Boone, our stu-
dent department worker, who helped us find updated book and website sources
found at the end of select chapters.
I, Katja Antoine, want to express my heartfelt gratitude to Muriel Vernon

for inviting me to participate in this project, and to Anne Bolin and Patricia
Whelehan for welcoming me as a contributor. I would also like to thank Linda
Martindale for her editing and manuscript preparation. Lastly, I wish to ex-
press my love and appreciation for my partner, Roland McFarland, for being
patient and feeding me when I spent weekends deeply immersed in revisions.
Taylor & Francis
Taylor & Francis Group
http://taylorandfrancis.com
1 Introduction
Chapter Overview
1 Introduces human sexuality from a biological, psychological, and cultural
perspective.
2 Discusses how the social control of human sexuality forms the fundamen-
tal basis for the functioning of human groups and group life.
3 Discusses ethnographic and comparative approaches to the cultural
patterning of human sexuality. Highlights anthropologists such as
Malinowski, Benedict, Mead, Ford and Beach, Martin and Voorhies, and
Frayser.
The Anthropological Perspective

In one ruling by the Supreme Court, sex was declared “a great and mysterious
motive force in human life [that] has indisputably been a subject of absorb-
ing interest” (in Demac, 1988: 41). As children, we hear our parents speak
euphemistically about the “birds and the bees,” and as adolescents we may
share late-night discussions with our friends about the “secrets” of intimacy;
as adult North Americans, our concerns are expressed in an array of new
“self-help” books on the subject, which flood the market every year. Problems
with human sexuality, such as sexual addictions and sexual desire disorders
(lack of interest in sex), have captured the imagination of the television, ra-
dio, and Internet news media as well as the Diagnostic and Statistical Manual
of Mental Disorders-V-TR (2000), the “Bible” of diagnostic criteria for men-
tal health professionals in the United States since 1968 (Tiefer, 2004: 133).
Obviously, the subject enthralls more than just Dr. Phil and Oprah; con-
troversies abound around sex-related issues, such as same-sex marriage and
abortion, in the United States. In addition, questions arise concerning the
impact of rising HIV rates globally and how access to sexually charged con-
tent through the Internet will affect human sexual expression today and in
the future.
Our intent is to offer a unique way of understanding ourselves as sexual be-
ings through the perspective of anthropology. Some of our readers may not be
familiar with what anthropology entails and might be wondering what exactly
2 Introduction
Spielberg’s Raiders of the Lost Ark or Holland’s Krippendorfs Tribe has to do with
a serious anthropological approach to sex. For those of you unfamiliar with an-
thropology, we welcome and invite you to explore an exciting new viewpoint
that you will find very interdisciplinary in approach. Anthropology is probably
the most interdisciplinary of all the fields engaged in studying sexuality (also
referred to as sexology). Sexology spans the social and biological sciences as
well as the humanities. For those of you majoring or minoring in anthropology,
we hope that our book inspires you to conduct further research on the subject
of human sexuality.
Sex as Biology, Psychology, and Culture

Confusion about what anthropology is stems from the interdisciplinary na-
ture of the field. An anthropological approach is one that incorporates an
understanding of humans as both biological and cultural beings. The term
bio-cultural is often used to describe this perspective. However, we are not
suggesting that these are the only two dimensions for interpreting sex; indeed,
sex has a very important psychological component as well. As anthropologists,
we regard the psychological component as part of how culture shapes our per-
sonalities in characteristic ways yet also allows for the diversity of individuals
as unique genetic entities. There is a feedback relationship between culture,
psychology, and the individual.
Therefore, to express the complexity of the relationship between biology
and culture to human beings, we have added the psychological dimension to
our mix, hereby highlighting the contributions of psychology and psycholog-
ical anthropology to the study of human sexuality. This accentuates the im-
portance of the individual in society by emphasizing her/his relationship to the
cultural context, including personality, motives, attitudes, values, perceptions,
and emotions. It is because of these individual differences that cultures are so
dynamic and ever-changing. Human beings are not just robots, blindly en-
acting their cultural scripts; they innovate, invent, resist, subvert, rebel, and
negotiate just as they may reproduce and subscribe to aspects of their cultures
(Basirico and Bolin, 2002). We have reframed our bio-cultural terminology as
“biological, psychological and cultural” to better reflect the role of individuals
within society (see Figure 1.1. For further discussion, see Chapter 2).
Although a biological, psychological, and cultural approach in anthropol-
ogy may not be appropriate for all subjects anthropologists might research,
such a view lends a fuller and more complete understanding for a number of
topics. Biological, psychological, and cultural perspectives are widespread in
fields such as medical anthropology, biological anthropology, the anthropol-
ogy of sex and gender, psychological anthropology, and clinical anthropology.
The interweaving of biology, psychology, and culture into a bio-psycho-
cultural perspective is the distinguishing feature of this book and the theme
that unifies the diversity of studying human sexuality through an anthropo-
logical lens. The term “sex” has many meanings. Sex is part of our biology. It is
Introduction 3
Psychological
Attributes
Genetics Individual Culture
Figure 1.1 The individual in society.

Source: Anne Bolin with Elon University Department of Instructional and Campus Technolo-
gies, 2006.
a behavior that involves a choreography of endocrine functions, muscles, and

phases of physical change. It is expressed through the “biological sex” of people
classified as male or female (Katchadourian, 1979). Despite this physiological
component, the act of sex cannot be separated from the psychological and
cultural context in which it occurs, thereby incorporating meanings, symbols,
myths, ideals, and values. Sex expresses variation across and within cultures,
and among individuals.
An anthropological definition of sex is necessarily broad and includes the
cultural, psychological, and biological aspects of sex. We shall offer you a defi-
nition of sex but urge you to remember that defining sex is far more com-
plex than our definition suggests. For example, our definition cannot limit
sex to only those behaviors resulting in penile-vaginal intercourse; in doing
so, we would eliminate a variety of homosexual, bisexual, and heterosexual
behaviors that are obviously sexual but not coital. Therefore, we shall define
sex as those behaviors, sentiments, emotions, and perceptions related to and
resulting in sexual arousal, as defined by the society or culture in which it
occurs. We qualified our definition by referring to cultural definitions of sex-
ual behaviors since these differ a great deal among ethnic groups and cross-
culturally. For example, “petting,” as we know it in industrialized societies, is
not universal, that is, it is not necessarily considered a form of arousal among
all other peoples of the world. As you read this book, you will begin to broaden
your understanding of yourself, your own society, and the multicultural world
in which we live.
Anthropological Perspectives on Human Sexuality

The study of human sexuality is cross-disciplinary. Six major perspectives
dominate the study. They include the biological, with a focus on physiology,
hormones, and anatomy; the psychosocial, which emphasizes the develop-
mental aspects of sexuality and the interaction of the effect of cognitive and
4 Introduction
affective states with social variables on the individual; the behavioral, which
stresses behavior over cognitive and emotional states; the clinical concern
with sexual problems and dysfunctions; the sociological, with a focus on social
structures and the impact of institutions and socioeconomic status factors on
sexual behavior; and the anthropological, which includes evolutionary and
cultural approaches, with emphases on sexual meanings and behaviors within
the cultural context. Culture is the shared reality of people that includes both
ideas and patterned behaviors within a group, community (geographical and
ideological), and/or region. Therefore, by culture, we mean the skills, attitudes,
beliefs, and values underlying behavior as well as the behaviors themselves.
These are learned by observation, imitation, and social learning. This prelimi-
nary definition is elaborated upon further in this chapter and Chapter 2.
In today’s global community, it is increasingly important for us to incorpo-
rate multicultural perspectives into our knowledge base. Since this approach
is at the heart of anthropology, we offer a brief historical overview of some of
the more well-known cultural anthropologists who have shaped the study of
human sexuality. The contributions of anthropologists studying the evolution
of human sexuality are discussed in Chapter 3.
Anthropology as a discipline developed in the nineteenth century. From its
inception, anthropologists have been interested in the role of human sexuality
in evolution and the organization of culture. Darwin, most well-known for
the biological theory of evolution (see Chapter 2 for definition and Chapter
3 for discussion), also formulated theories on culture that included ideas on
human sexuality. These were presented in The Descent of Man and Selection
in Relation to Sex (1874 [1871]). Darwin argued that morality is what separates
humans from animals. In his theory of morality, he regarded the regulation
of sexuality as essential to its development. According to him, marriage was
the means for controlling sexual jealousy and competition among males. Over
the course of moral evolution, restrictions on sexuality were first required of
married females, then later all females; finally, males restricted their own sexu-
ality to monogamy. Darwin’s approach incorporated notions of male sexuality
and assertiveness, and female asexuality. These views reflected Darwin’s own
cultural beliefs about sex and gender (Martin and Voorhies, 1975: 147–149).
Other nineteenth-century anthropologists also produced theories of social
evolution that included the regulation of sexuality. John McLennan (1865),
John Lubbock (1870), and Louis Henry Morgan (1870) conceived of societies
as having evolved through stages. These stages represented increasing restric-
tions on sexuality as societies progressed from the allegedly “primitive” stages
of promiscuity to modern “civilization,” characterized by monogamy and pa-
triarchy (Martin and Voorhies, 1975: 150). These theories were flawed in that
they regarded European culture as superior and viewed social evolution as an
unwavering linear trend of “progress.”
The twentieth century brought new approaches to the study of human sexu-
ality as anthropology shifted from grand evolutionary schemes with little rigor
to empirically oriented studies. This transition led to a new methodology, for
Introduction 5
which anthropology has gained acclaim. Bronislaw Malinowski is the acknowl-
edged parent of the anthropological research method known as ethnography.
Ethnography is the research method of participant-observation in which the
anthropologist becomes entrenched in the lives of people in their research
community. The ethnographic method serves as the basis for an ethnography,
the detailed study of the culture of a particular group of people. Malinowski
is known for his analysis of sex as part of the ethnographic context. His
groundbreaking work titled The Sexual Life of Savages in North-Western Mela-
nesia: An Ethnographic Account of Courtship, Marriage and Family Life Among
the Natives of the Trobriand Islands, British New Guinea was first published in
1929. Although others in the 1920s wrote about indigenous peoples and their
sexuality, their approaches, unlike Malinowski’s, were not based on firsthand
research but rather on missionary and travelers’ reports or short-term field proj-
ects (Weiner, 1987: xiii–xiv). Malinowski’s two-year term living with the Mel-
anesian Trobriand Islanders and his scientific and systematic methods of data
collection left an important legacy for the field of anthropology and the study
of human sexuality.
Malinowski was interested in the relationship of institutions such as kin-
ship to cultural customs, including sexual behaviors. His perspective stressed
the importance of the cultural context and emphasized how social rules or-
dered sexuality among the Trobriand Islanders. What appeared to Europeans
as unrestrained sexuality were in fact highly structured premarital sex rules
and taboos based on kinship classification (Weiner, 1987: xvii). Malinowski
seriously challenged the dominant nineteenth-century cultural evolutionism
of McLennan, Lubbock, and Morgan. He rejected the notion that early human
life was represented by sexual promiscuity. The Trobriand Islanders illustrated
that even the most non-technologically complex peoples regulated their de-
sires through systems of kinship. Rather than promiscuity as a prior condition,
Malinowski focused on the patterning of sexual relations in creating the fam-
ily (Weiner, 1987: xxv–xxvi).
He was also influenced by another trend impacting anthropology: that of
psychoanalysis. He was impressed with the psychoanalytic openness to the
study of sex but was critical of Sigmund Freud’s theory of the incest taboo and
the Oedipus complex. In a nutshell, Freud’s argument is that little boys uncon-
sciously experience a desire to marry/have sex with their mothers and want to
murder their fathers, whom they regard as rivals. In Sex and Repression in Sav-
age Society (1927), Malinowski “argued that Freud’s theory of the universality
of the Oedipus complex needed revision because it was culturally biased. Freud
based his theory on the emotional dynamics within the patriarchal western
family” (Weiner, 1987: xxi). This resulted in a heated debate with psychoan-
alyst Ernest Jones. Malinowski again argued that the Oedipus complex was a
result of the European patriarchal family complex. The Trobrianders presented
quite a different picture from the European nuclear family; their culture is a
matrilineal one—that is, people traced their ancestral descent through their
mother’s family. This produced different family dynamics, leading Malinowski
6 Introduction
to conclude that the Trobrianders were free of the Oedipus complex. Unfor-
tunately, his work did not influence the psychoanalytic position to any great
degree. For a more detailed discussion, see Chapter 10.
Ruth Benedict and Margaret Mead loom large in the history of anthro-
pology and in their respective contributions to the study of sex. Both were
students of Franz Boas, the parent of US anthropology. Benedict’s contribu-
tion continues to be felt today. Her perspective, in revised form, is embedded
in contemporary anthropology in the concepts of ethos (the “approved style
of life”) and worldview (the “assumed structure of reality”) (Geertz, 1973:
126–141). Benedict’s Patterns of Culture, published in 1934, offered an ap-
proach in which cultures were regarded as analogous to personalities. She
stressed how each culture produced a unique and integrated configuration.
This was known as the configurational approach and was popular in the
school of thought known as culture and personality (Benedict, 1959: 42–45).
Benedict was deeply committed to diversity and to those relegated to the
margins of society. This was demonstrated in her concluding chapter, in which
she reiterated points from her paper “Anthropology and the Abnormal” (1934).
She was concerned with individuals whose temperaments did not match their
cultural configuration and the psychic costs to those, such as homosexually
oriented people, who were “not supported by the institutions of their civiliza-
tion” (in Bock, 1988: 52). She proposed that “abnormality” was not constant
but rather is culturally constituted. She suggested what, at that time, was a
radical view: tolerance for non-normative sexual practices, such as homosex-
uality. Implicit in her view is the idea that sexuality is no different than any
other social behavior; it is culturally patterned. Benedict argued that “in a
society that values trance, as in India, they will have supernormal experience.
In a society that institutionalizes homosexuality, they will be homosexual” (in
Singer, 1961: 25). She challenged prevailing notions of homosexuality as pa-
thology. In 1939, she concluded, in Sex in Primitive Society, “that homosexuality
was primarily social in nature, shaped by the meanings of gender and sex roles”
(Dickermann, 1990: 7).
For the study of human sexuality, Benedict’s major contribution was the
idea that sex—which is a part of culture—is patterned, fitting into the larger
society, the cultural whole, or the gestalt. The configurational approach was
certainly not without flaws, and anthropology has moved beyond regarding
cultures as personalities. However, Benedict left an important legacy for an-
thropology in her emphasis on patterning, cultural holism, and sensitivity to
difference. For the field of sexology, Benedict was bold and unafraid in her
perspective on sexual variation.
Margaret Mead was also an important and powerful figure in anthropology
and sexology. Before her death in 1978, she was more widely recognized for
her work than any other anthropologist in the world. In numerous books and
articles, Mead addressed the subject of sex and gender. Although her contribu-
tions are many, we shall focus on her first book, Coming of Age in Samoa (1961
[1928]), investigated when she was not yet twenty-four-years old.
Introduction 7
Mead was a proponent of cultural constructionist explanations of human
behavior. She explained this approach by saying:
It was simple—a very simple point—to which our materials were orga-
nized in the 1920s, merely the documentation over and over of the fact
that human nature is not rigid and unyielding, not an unadaptable plant
which insists on flowering or becoming stunted after its own fashion,
responding only quantitatively to the social environment, but that it
is extraordinarily adaptable, that cultural rhythms are strong and more
compelling than the physiological rhythms which, they overlay and
distort. . . . We had to present evidence that human character is built
upon a biological base which is capable of enormous diversification in
terms of social standards.
(in Singer, 1961: 16)
In Coming of Age in Samoa, her commentary addressed female adolescence

in Samoa as well as in the United States. She proposed that the turbulence
of US girls’ adolescence was not typical of adolescence throughout the world.
Mead was responding to a popular biological theory of adolescent “stress and
storm,” believed to be caused by the changes in hormones during puberty
(not unlike the “raging hormones” view of adolescence and PMS popular
in today’s media). Her study of Samoan adolescence provided a very differ-
ent picture. Unlike US adolescence, the Samoan youth did not experience a
period of turbulence and high emotion. Based on evidence of a carefree Sa-
moan adolescence, Mead reasoned that the conflict experienced by US teen-
agers was due to cultural influences rather than hormones. The latter part of
Coming of Age in Samoa explained the strife of US adolescence as a cultural
phenomenon. Mead offered explanations that emphasized the importance of
culture in shaping behavior. For example, she identified the importance of
rapid culture change in US society as contributing to the turmoil so typical
of adolescence.
In contrast, Mead argued, the Samoan girls’ adolescence was conflict free.
This was due to Samoan culture, which was relatively homogeneous and ca-
sual. So casual that according to Mead, the young woman:
defers marriage through as many years of casual love-making as possible…

The adolescent girl’s total interest is expended on clandestine sex adven-
tures… to live with as many lovers as possible and then to marry into one’s
village…
(Mead, 1961 [1928]: 157)
Samoan society was one in which extremes in emotion were culturally dis-
couraged. It was characterized by casualness in a number of spheres, in-
cluding sexuality, parenting, and responsibility. In contrast to industrialized
culture, a young Samoan woman’s sexuality was experienced without guilt.
8 Introduction
She concluded that the foundation of this nonchalant approach to sex and
conflict-free adolescence could be explained by the following:
• A dearth of deep feeling between relatives and peers.

• A liberal attitude toward sex and education for life.
• An absence of conflicting alternatives.
• A lack of emphasis on individuality.
In this work, she established the importance of the study of women when little
information was available (Howard, 1993: 69). She also challenged notions of
biological reductionism that, even today, are too often used to support status
quo politics.
Despite the magnitude of Margaret Mead’s contribution to anthropology,
and her recognition as a public figure who brought anthropology out of the
halls of academia into the mainstream United States, she was not without her
detractors. Since her death in 1978, Coming of Age in Samoa has been at the
center of a heated debate in anthropology launched by Australian anthropol-
ogist Derek Freeman in his book Margaret Mead and Samoa: The Making and
Unmaking of an Anthropological Myth in 1983 and his subsequent 1999 book
The Fateful Hoaxing of Margaret Mead: A Historical Analysis of Her Samoan Re-
search. Derek Freeman argued strongly for a very different Samoa from the one
studied by Mead. Based on his own research in Samoa from 1940–1943 and ex-
tensive subsequent research in the 1960s, Freeman took issue with the picture
of the easygoing family life, low affect, and positively sanctioned premarital
sex, citing punitive family relationships, competition and aggression, sexual
jealousy, and a stormy puberty. His explanations are in direct opposition to
those of Mead; he weighed in on the “biology is destiny” spectrum arguing
for instinctive and innate interpretations of his findings. Freeman, however,
did not disagree with Mead’s depiction of adolescent casual attitudes toward
adolescent sex (in Barnouw, 1985: 98–99). In his second attack, he argued
that Mead’s two key informants deliberately lied to her. Just as Freeman has
critiqued Mead, other anthropologists have found much lacking in Freeman’s
evidence (Cote, 2000; Ember, 1985; Holmes, 1987), yet others have argued that
they were both partially correct (Abramson, 1987; Shankman, 1996; Ember
and Ember, 1994).
The different conclusions can be attributed to several factors, including
the gender of the fieldworker, which can have a decided effect on developing
rapport and on the kind of data collected (Holmes, 1987). There was also a
fourteen-year gap in time between when Mead finished her research in 1926
and Freeman started his in 1940. Samoan culture had changed a great deal
since the 1920s with the impact of missionization, colonialism, increasing
Euro-American contact, globalization, and the expansion of capitalism, which
undoubtedly affected Freeman’s interpretation of Samoan adolescent behavior
(Ember, 1985: 88; Ember and Ember, 1994; Shankman, 1996). Mead worked
primarily with adolescent girls while Freeman’s main sources were senior men
Introduction 9
whose knowledge of what teenage girls were experiencing was undoubtedly
limited. Abramson’s research supports the view that adults opposed premarital
sex, but in spite of this, Samoan adolescents had frequent premarital sex (in
Bates and Fratkin, 2003: 65–66). Not only did Mead and Freeman rely on dif-
ferent populations for research, but they also studied on different islands whose
history of colonization varied as well. Mead studied in American Samoa while
Freeman worked mostly in the Independent State of Samoa (Ember, 1985: 87).
Shankman has argued that the disagreement may lie in the vantage point
of comparison. Thus, compared with the United States at the time, Samoan
premarital sexuality may have indeed been more common and open (Ember
and Ember, 1994). In addition, Freeman has criticized Mead for too heavy a
reliance on her two key informants and not collecting enough divergent views.
However, Cote (2000) and Shankman (1996: 564) have critiqued Freeman’s re-
search on the same grounds: that he has selectively used information that sup-
ports his stance while ignoring evidence which substantiated Mead’s claims.
The general consensus by anthropologists is that Mead may have over-
stressed the homogeneity of Samoan culture and adolescent experiences, but
her general stance, that culture is a tour de force in shaping the expression
of gender and influencing biological differences in the sexes to a very strong
degree, is supported by the huge range of variation in the expression of gender
found cross-culturally. Finally, Freeman claims to “Unmake… an Anthropo-
logical Myth” by focusing his critique on one of her earliest works undertaken
when she was just twenty-four-years old and by ignoring an entire lifetime of
research publications. As such, this is a rather extreme claim. Indeed, this on-
going debate confirms one of our favorite quotes by Margaret Mead: “Sooner or
later I am going to die, but I’m not going to retire” (Brainy Quotes).
[Margaret Mead and Ruth Benedict’s] view of culture as a pattern or config-

uration of homogenous and integrated elements, often linked with a unified
theme, lacks the dimensions of contemporary theories. Now anthropolo-
gists think that culture is never simple, uniform or well integrated. It is a
messy, complicated, and often contradictory set of differences or oppositions
that may exist side by side within the same group claiming the same terri-
tory, history, or worldview. This is why, today, we can talk of a female culture
and a male culture with complex and contradictory ethnic, national and
world cultures.
(Ward and Edelstein, 2006: 62)
Although the approaches of Malinowski, Benedict, and Mead contributed to

the creation of the ethnographic study of sexuality with an emphasis on the
cultural, Clellan S. Ford and Frank A. Beach’s Patterns of Sexual Behavior de-
serves credit in 1951 for offering the first synthetic study that incorporated
biological, cross-cultural, and evolutionary considerations. Their work is dis-
tinctive for its inclusion of homosexual and lesbian data; a trend continued
in Gregerson’s 1994 The World of Human Sexuality: Behaviors, Customs and
10 Introduction
Beliefs. According to Miracle and Suggs (1993: 3), Ford and Beach’s book is
“[t]he single most important and provocative work on sexuality to date… It
also provided the intellectual—if not the methodological—foundation for the
subsequent work of Masters and Johnson” (see Chapter 12 for a discussion of
Masters and Johnson). Patterns of Sexual Behavior integrated information from
190 different cultures as well as provided comparative data on different species
with an emphasis on the primates (humans, apes, and monkeys). Their work
includes an encyclopedic collection of sexual behavior cross-culturally. For ex-
ample, Ford and Beach offer discussion and information on sexual positions,
length (time) of intercourse, locations for intercourse, orgasm experiences,
types of foreplay, courting behaviors, frequencies of intercourse, methods of
attracting a partner, among numerous other topics.
Ford and Beach’s study of human sexuality employed the cross-cultural
correlational method. This is a statistical method for comparing attributes
(variables) in large samples of diverse cultures (Cohen and Eames, 1982:
419). This approach is valuable for testing hypotheses about human sex-
uality, establishing patterns and trends, and formulating generalizations.
Their study relied on ethnographic data that is collected and coded in
the Human Relations Area Files (HRAF). HRAF is a rigorous classifica-
tion scheme for information on the world’s societies containing descriptive
ethnographic data. Categories of information for 350 societies, based on
a 900,000-page database of more than 7,000 books and articles are coded
and available to researchers. These data are digitized (Bernard, 1994: 343).
A caveat for the student researcher is that the HRAF data for a particular
society may not take into account historical context and culture change,
particularly the more recent impact of globalization (Scupin and De Corse,
1998: 307).
The cross-cultural correlational statistical method was subsequently used
by Martin and Voorhies in Female of the Species (1975). Like Ford and Beach,
Martin and Voorhies included evolutionary and biological issues. Their fo-
cus was broader in that they were interested in the relationship of human
sexuality to gender status/roles, social organization, and type of subsistence
(how people make a living). Martin and Voorhies tested hypotheses to ar-
rive at generalizations about the relationships of these factors. In a sample
of fifty-one foraging societies, Martin and Voorhies found that 30 percent
of them allowed premarital sexual experimentation (1975: 188-189). This
pattern was related to matrilineality (where descent is traced through the
mother’s side of the family) and matrilocality (where the couple resides in
the community of the wife’s mother). Their studies of horticultural groups
also revealed a statistical correlation between matrilineal societies and sex-
ual permissiveness toward premarital sex, while patrilineal (tracing descent
through the father’s side) societies tended to control female premarital sexual
behavior (1975: 246-247).
There are many research applications for this methodological approach
to sexological research. For example, Schlegel and Barry in Adolescence: An
Introduction 11
Anthropological Inquiry (1991) report that premarital restrictiveness occurs
in societies in which a dowry is given (wealth from the bride’s family is in-
cluded in the marriage transaction). They conclude that “[f]amilies guard their
daughters’ chastity in dowry-giving societies in order to protect their prop-
erty (dowry) against would-be social climbers and to ensure that they can use
their daughters’ dowries to attract the most desirable sons-in-law” (Schlegel
and Barry, 1991: 116). Chastity rules guard against a lower-status man impreg-
nating a higher-status woman and thereby making claim on her dowry and
inheritance by trapping her into marriage. In this way, property exchange and
status considerations are factors in restricting premarital sexuality (Schlegel
and Barry, 1991: 117-118). Davis and Whitten report that the general pattern
found in HRAF studies such as these is that sexual restrictions tend to be as-
sociated with complex societies (1987: 74).
Frayser’s Varieties of Sexual Experience (1985) continues the tradition
spawned by Ford and Beach, incorporating the cross-cultural correlational
approach with biological and evolutionary concerns. Frayser presents an in-
tegrated model in which human sexuality is regarded as “a system in its own
right, related to but not subsumed by social, cultural, psychological, and bi-
ological factors” (Frayser and Whitby, 1987: 351). For Frayser, although the
cross-cultural record reveals an almost infinite variety in sexual expression,
there is continuity with our evolutionary past. In regard to evolution, Frayser
examines cross-species sexuality, particularly that of our close relatives, the
nonhuman primates. For example, she points out that human sexuality is dis-
tinguished by unique sexual and reproductive attributes, including the poten-
tial for sexual arousal that is not limited to estrus (“heat”) and the evolution
of the female orgasm. These capabilities are present in our relatives to a lim-
ited extent but emerge full blown in humans and are linked to extraordinary
amounts of nonreproductive sexual behavior among humans in comparison
with other animals.
Frayser has distinguished the social and cultural aspects of human sexu-
ality in terms of the social system defined as “patterned interactions.” The
social system is contrasted to the cultural system, which Frayser defined
as the “patterned beliefs and meanings” that influence sexual expression
(Frayser, 1985: 7). This model is one in which the biological, the social, and
the cultural system converge to influence the sexual system. It is a valuable
approach for understanding sexual patterning and for recording the conti-
nuities and heterogeneity within and between cultures. However, it should
be noted that anthropologists’ definitions for the social and cultural system
are often quite divergent. For example, many anthropologists do not limit
their definition of the cultural system to the ideological realm but include
behaviors as well. Others define the social system functionally as “institu-
tions,” recurrent patterns that fulfill human needs such as the family and
religion (Bates and Fratkin, 2003: 45). See the last section of this chapter,
“The Patterning of Human Sexuality,” for a more detailed discussion of the
culture concept.
12 Introduction
Sex as Culture
The regulation of human sexual expression as to “when, where, how, and who”
may serve diverse socio-cultural goals. George Peter Murdock’s pioneering study,
Social Structure (1949), offers us a classic approach to the different ways that the
regulation of sexuality contributes to the organization of cultures. In all societies,
sexual access among members of a society is regulated. The most obvious exam-
ple of this is the incest taboo. With an almost universal prevalence, the incest
taboo prohibits sexual access between siblings and between siblings and their
parents. Even in those societies that have allowed incest, regulations surround
it that are integrated in the wider social organization and belief system. The ex-
ceptions include Hawaiian royalty, the ancient Egyptian pharaohs and nobility,
and Inca emperors. These elites, usually brothers and sisters, were regarded as so
powerful and sacred that only their very close relatives had the equivalent status
to qualify as a mate and to perpetuate the lineage. Such sexual unions and mar-
riages were not allowed, however, for the population at large (Murdock, 1949: 13).
Rules for sexual access also extend beyond the immediate nuclear family.
Exogamy is a rule requiring that people marry outside their group, while en-
dogamy specifies marriage within the group, but not the immediate family.
These rules create kin groups through different kinds of restrictions on sexual
access. Rules of exogamy and endogamy are defined by reference to marriage.
This illustrates how sexual ideologies are integrated in the social organization
of kin groups; but one should not make the error of thinking that sex and
marriage are always equated. This is a mistake often found in the literature on
human sexuality, but one seldom made by the people involved in extramarital
affairs. “Marriage is a publicly recognized union between two or more people
that creates economic rights and obligations within the group… and guar-
antees their offspring rights of inheritance” (Crapo, 1987: 148). It is regarded
as an enduring relationship and includes sexual rights (Ember and Ember,
1988: 13). Murdock (1949: 8) offers clarification:
Sexual unions without economic co-operation are common, and there

are relationships between men and women involving a division of labor
without sexual gratification, e.g., between brother and sister, master and
maidservant, or employer and secretary [sic], but marriage exists only
when the economic and the sexual are united in one relationship, and
this combination occurs only in marriage.
Ford and Beach’s pioneering Patterns of Sexual Behavior (1951) proposed that
sexual partnerships consist of two types: mateships defined in the same way as
marriages; and liaisons, “less stable partnerships in which the relationship is
more exclusively sexual” (1951: 106). Sexologists and anthropologists generally
subdivide human liaisons on the basis of their premarital or extramarital char-
acter (Ford and Beach, 1951: 106).
The regulation of sexual partnerships makes it possible to define groups of
people by relationships based on offspring and kinship. These kin relationships
Introduction 13
are formalized through marriage systems. Sexual prohibitions function to
“minimize competition among relations and to increase the bonds of cooper-
ation and friendship between neighboring groups” (Crapo, 1987: 61). Because
descent is important for a number of reasons such as inheritance, obligations,
and affiliations, we can regard sexual unions as having the potential to shape
kin group formation; sexual access therefore defines kin groups. The impor-
tance of sexuality is socially recognized through marriage as an institution
with sexual rights and obligations. But it should be kept in mind that there
is a great deal of sexual activity that occurs prior to and outside marriage, in-
cluding sexual activities between people of the same sex, ritual and ceremonial
sex, as well as a host of other encounters including affairs, “one-night stands,”
and “hooking up.”
Societies differ as to their tolerance of premarital and extramarital activities
and the conditions under which they are acceptable and/or prohibited. Ac-
cording to Broude and Greene’s (1976) survey of the cross-cultural record, in
69 percent of the societies studied, men commonly participated in extramar-
ital sex, and in 57 percent of the societies women did so as well. This leads us
to another thorny issue for sex researchers, the contrast between ideal and real
culture. The ideal culture or normative expectation is that 54 percent of the
societies surveyed allow only men to have extramarital sex, while 11 percent
allow it for women. But the data suggest that many more people worldwide
actually violate this ideal, particularly in the case of women.
In summary, human sexuality is a central force in the origin of kin groups.
In Murdock’s words: “All societies have faced the problem of reconciling the
need of controlling sex with that of giving it adequate expression” (1949: 261).
The regulation of sexual relations is the basis for descent and inheritance,
critical factors for human societies in the maintenance of social groups. Yet sex
and marriage do not necessarily “go together” like a horse and carriage. Sex is
not the central factor in the bonding of two individuals through marriage. To
think so is to engage in a bias shaped by recent modern US views of marriage.
Sex is indeed critical for kin groups and their perpetuation; although sex is a
right and an obligation in marriage, it is not necessarily the basis upon which
marriages are made. Economic cooperation emerges as an important factor
in marriage both in evolutionary terms and in the cross-cultural record. This
will become more evident in our discussion of “The Patterning of Human
Sexuality.”
The Patterning of Human Sexuality: The Biological,

Psychological, and Cultural Perspective
This section emphasizes the relationship between biology, psychology, and
culture. These three dimensions necessarily have a psychological component
as well. As stated earlier, the psychological theme emphasizes the importance
of individuals’ relationship to their cultural context. And from a biological
perspective each person has a unique genetic heritage (with the exception of
14 Introduction
identical twins). This aspect is elaborated upon more in Chapter 2. Human
sexuality has a foundation in human biology, which provides us with certain
inherited potentialities. “The inherited aspects of sex seem to be nearly form-
less.” It is only through culture that sex assumes form and meaning (Daven-
port, 1977: 161) (see Figure 1.1).
Our human biological wiring is very different from what we think of as
animal instinct. For example, the drive for food that allows us to survive is
fulfilled through learning how to get food; in some cultures people collect food
by fishing, and in others, they go to the grocery store. The desire for sex is also
shaped by culture and is very unlike a mating instinct. When a female ani-
mal comes into heat, she naturally and necessarily (through hormonal mecha-
nisms) becomes sexually responsive and follows her mating instinct. Humans,
however, may ignore their drives and or desires. For example, Buddhist monks
traditionally deny their sexuality in order to live in celibacy as required by
their religion (Ruan and Lau, 2004: 187).
Others delay sexuality until marriage, which may not occur until their
twenties or later. For example, in the Irish community of Inis Beag, Messenger,
whose research spanned 1958–1966, found that the average age of marriage
was thirty-six for men and twenty-five for women (Messenger, 1971).
Human biological predispositions are not “rigidly determined…. They
may orient us in particular directions in pursuing certain goals, but they do
not determine our behavior in a mechanical fashion without learned expe-
riences” (Scupin and De Corse, 1992: 164). This biological underpinning to
our sexuality and other behaviors is part of what is called an open biogram,
“an extremely flexible genetic program that is shaped by learning experiences”
(Scupin and De Corse, 1992: 164). Humans acquire their culture through the
process of socialization. This capacity to learn and to adapt to one’s environs
is a part of our unique bio-cultural and psychological evolution as humans. We
can say that our biology sustains us as cultural beings by providing us with an
unusual aptitude for learning.
Sexual behavior is culturally patterned; it is not accidental or random but
is interconnected and/or integrated to varying degrees (this itself is of interest
to anthropologists) within the broader context of culture and is intermeshed
in a web of other cultural features as we have seen in our discussion of sex,
marriage, and kinship. A number of cultural characteristics are associated
with patterns of human sexuality. These may include: the level of technology,
population size, religion, economics, political organization, medical practices,
kinship structure, degree of acculturation and culture change, gender roles,
power and privilege (stratification). Consequently, larger cultural patterns are
important in shaping reproductive and nonreproductive sexual behaviors and
values in a society. Sexuality is patterned across cultures in relation to these
variables as well as within a culture. Davenport suggests that sex is molded
by the “internal logic and consistency of the total culture. As one sector of
culture changes, all other sectors that articulate must undergo adjustments”
(1977: 162). However, as we noted, cultural systems are never simple and the
Introduction 15
interconnections between the elements of culture are often intertwined with
oppositions and contradictions.
Cultures are systems that exist within particular environmental and histor-
ical contexts. We have discussed the biological basis of human sexuality; we
offer now an overview of the cultural basis of human sexuality. To comprehend
how sexuality is embedded in culture necessitates an understanding of the cul-
ture concept. We can think of culture in terms of architecture1 (see Figure 1.2).
In Figure 1.2 the basement represents our biology as humans, including our
evolution and physiology. The floor in Figure 1.2 is the foundation for under-
standing that cultural variation rests in how humans have adapted to their
environments. This includes how people make a living, their technologies, and
economics. There are a number of ways people have found to survive in the
world. Anthropologists have classified societies in terms of foraging, horticul-
ture, agriculture, pastoral (herding), industrial, and postindustrial adaptations.
Adaptation to the environment impacts the social system including social
organization and social structures, which may be likened to the frame of a
house. The social system is the means that people adapt to one another. It
includes social organization and its elements including kinship and marriage,
and various institutions and structures such as religion and political organi-
zation. The social system is influenced by how people make a living through
demographics; the relations of work, such as age, gender, and kinship; who
Ideology THE ROOF

and value
system
Social systems
THE FRAME
Adaptations to the environment—how

humans make a living in a FLOOR
particular ecosystems
Human biology—
BASEMENT
evolutionary adaptation
Figure 1.2 Culture as architecture.

Source: Anne Bolin with Elon University Department of Instructional and Campus Technolo-
gies, 2006.
16 Introduction
controls the means of production; and the power relations of society. Societies
have been classified in terms of their social systems as bands, tribes, chiefdoms,
preindustrial states, and nation states.
The roof of our building may be conceptualized as the ideological value
system. This is the system of meanings and beliefs in a culture. It includes
expressive elements of culture like art, music, rituals, myths, folklore, and cos-
mology. It is the meanings and beliefs behind and sustaining the patterning of
cultures such as marriage norms, gender roles, courtship, etc. The foundation,
the frame, and the roof are all interrelated parts of the cultural whole.
Human sexuality is part of that cultural whole. We may first encounter it
in the basement in terms of our evolution and our unique human physiology.
To grasp human sexuality as part of a cultural matrix we may locate it in any
of our architectural levels. For example, in investigating beliefs about human
sexuality, we might begin with our roof (ideology and the value system). We
may observe that a particular culture has very few restrictions on premarital
sex. In this culture, premarital sex among adolescents may be regarded as an
amusement (Schlegel and Barry, 1991: 21), as part of an experiential kind of
sex education, or perhaps as a way to find a marriage partner. In short, there
are numerous meanings and beliefs around premarital permissiveness among
cultures which allow and encourage its practice.
In order to see how the meanings behind premarital sex are part of the
interconnections within a cultural system, we will want to investigate how pre-
marital sex relates to the broader social system. As we saw earlier, Martin and
Voorhies (1975) found a correlation between matrilineal social organization
and premarital permissiveness, while patrilineal social organization was cor-
related with restrictions on female premarital sexuality. From this correlation,
explanations may be proposed. After reading about the relationship between
premarital sexuality and matrilineality/patrilineality, what explanation can
you think of to account for this difference?
To be even more rigorous in our investigation of premarital sexual permis-
siveness requires an analysis of the foundation of culture: adaptation to the
environment or how people make a living and survive in a particular locale.
For example, agricultural systems are associated with higher populations, strat-
ification, and greater social complexity. Earlier we noted in the work of Da-
vis and Whitten (1987: 74) that the greater the socio-cultural complexity, the
more likely there are to be premarital restrictions on sexuality.
Since subsistence type is associated with complexity, it has been argued that
foragers and matrilineal horticulturists are more likely to be sexually permis-
sive than agriculturalists (Martin and Voorhies, 1975). This approach allows us
to see the connections between sexual practices, kinship, social organization,
and how people make a living. To understand how permissiveness or restric-
tions influence individuals and their sexuality, the psychological dimension
may be brought in. Ethnographic studies often provide insights into how the
cultural system influences individuals in terms of motives, emotions, and feel-
ings. For example, the Mead (1961 [1928]) and Freeman (1983, 1999) debate
Introduction 17
includes this psychological dimension. Individual expressions of jealousy and
casual affect (feelings) toward sexual encounters were emphasized by Mead
and contested by Freeman.
Our analysis could go even further and include the biological. For example,
research into premarital permissiveness among foragers will reveal that adoles-
cent sterility may be a variable to be considered (see Chapter 11). Adolescent
sterility is a period of infertility among young females after the onset of men-
arche. They are not fertile until their late teens or early twenties. If premarital
sex is allowed in societies in which this occurs, young people may explore
their sexuality without the consequences of pregnancy and responsibilities of
parenthood.
We offer this architectural approach to culture and sex to illustrate that
culture is a complex whole in which the parts are interrelated. One can be-
gin anywhere in our biological, psychological, and cultural architecture and
explore human sexuality. Some researchers prefer limiting their research to
one area; for example, Masters and Johnson’s investigations of human sexual
response have focused on the biological. Others, such as the anthropologists
cited, may be more interested in the relationship between beliefs and premar-
ital sex practices and how these are related to social organization. Yet others
may want a bigger picture and explore how premarital sex norms are related to
the types of subsistence adaptation.
In offering this overview of culture, it should be remembered that what the
ethnographic study reveals represents a particular point in time. Cultures are
not static entities, and change is ongoing. Immigration has been going on for
2 million years ever since Homo erectus (one of our hominid ancestors) left
Africa and went as far as China carrying with her/him tool traditions and
cultural practices. Anthropologists no longer assume that tribal peoples lived
unchanging isolated lives for thousands of years.
The indigenous Australian people of Arnhem Land had a long history

of contact with Macassan (Indonesians from Sulawesi) mariners. The
Arnhem Land aboriginal people learned to make sea-going dugouts from
the Macassans who came to fish for trepang (sea slugs). In exchange for
their help collecting the trepang, they were given cloth, iron, glass, and
pottery. This exchange occurred for hundreds of years, beginning around
1720 (some suggest possibly 300 years earlier) and continually occurred
until 1906 when government regulations ended it. This cultural encoun-
ter left a cultural legacy in terms of art, oral history, development of a
trading language, and the exchange of genes. Some went willingly with
the Macassans, while others, such as Yolgnu women, were abducted, and
others were forcibly traded (Nannup, n.d.; Singh, et al., 2001: 69).
18 Introduction
Thus, cultures are dynamic and even the most traditional culture does not re-
main static. This is due to a number of factors. Because individuals are not all
the same, they actively negotiate their culture through lived experiences and
consequently change occurs. In addition, as humans modify their environ-
ments, their populations may grow, and the demand for technologies to solve
new problems caused by the changing circumstances occurs. Human groups
have never lived in isolation, and contact with other peoples leads to culture
change as well. Culture is a dynamic and ever-changing process. However, a
strong argument can be made that the rate of change has been dramatically
increased as a result of colonialism, and more recently globalization with the
expansion of capitalism worldwide. Indigenous and tribal peoples have been
particularly impacted by globalization. In terms of human sexuality, culture
change, colonialism and globalization have huge implications for issues in sex-
uality, particularly as these are related to women. In the barred text, Yolgnu
women were abducted and traded (this is referred to as trafficking). For further
discussion of the globalization of sex and trafficking see Chapter 17.
These are the kinds of opportunities for understanding human sexuality of-
fered by a biological, psychological, and cultural perspective. We hope this ap-
proach will allow students and other readers a greater awareness of themselves
as sexual beings, a greater understanding of themselves as cultural creatures,
and an appreciation of our evolutionary past and biological heritage.
Summary
1 Human sexuality is a biological, psychological, and cultural experience
and phenomenon.
2 Human sexuality is a means used by human groups to achieve socio-
cultural goals, such as the creation of kin groups.
3 A variety of anthropological perspectives and their proponents were in-
troduced, including Malinowski, Benedict, Mead, Ford and Beach, Martin
and Voorhies, and Frayser.
4 We concluded that human sexuality has several components, one in
human biology, which provides us with certain potentials and limitations,
and the other in culture, wherein our sexuality is learned and integrated
in the broader cultural context.
5 Emphasis was placed on the importance of the individual in society through
her/his relationship to the cultural context including motives, personality,
attitudes, values, perceptions, and emotions. It is because of these individ-
ual differences that cultures are so dynamic and ever-changing.
6 We discussed the value of a biological, psychological, and cultural per-
spective for understanding human sexuality.
7 We offered discussion of the culture concept, including discussion of the
dynamic elements of culture and introduced the importance of culture
change for understanding human sexuality.
Introduction 19
Thought-Provoking Questions
1 After reading this chapter, reflect on how your views about human sexu-
ality have been affirmed, challenged, or expanded?
2 What did you learn about human sexuality in this chapter that was
unexpected?
3 What makes anthropological perspectives on human sexuality unique?
4 What are some of the ways in which human sexuality is shaped by culture?
Can you think of any sexual or related behavior that is completely nat-
ural? Would you regard breastfeeding as completely natural without any
cultural influences?
Suggested Resources
Books
Holmes, Lowell Don. 1987. The Quest for the Real Samoa: The Mead/Freeman Contro-
versy and Beyond. South Hadley, MA: Bergin and Garvey.
LaFont, Suzanne, (ed.). 2003. Constructing Sexualities: Readings in Sexuality, Gender
and Culture. Upper Saddle River, NJ: Prentice Hall.
Websites
American Anthropological Association. http://www.aaanet.org.
International Academy of Sex Research. http://www.iasr.org/.
National Sexuality Resource Center. http://www.cregs.sfsu.edu.
Center for a Public Anthropology. http://www.publicanthropology.org/index.htm.
2 Biological, Psychological, and
Cultural Approaches
Georgina S. Hammock
Chapter Overview
1 Compares and contrasts psychological, sociological, and biological per-
spectives of human sexuality.
2 Presents anthropological concepts, terms, and definitions. Specific exam-
ples from the fields of physical anthropology and cultural anthropology
that are relevant to our understanding of sexology are offered.
3 Provides a definition of and discusses the scope of human sexuality.
4 Offers the importance of a relativistic perspective of human sexual
expression.
5 Discusses sexual violence from various socio-cultural and legal perspectives.
Human behavior is an incredibly complicated phenomenon. Indeed, it is argu-

ably one of the most complicated topics that science has tried to understand and
explain. Many factors and variables influence human behavior and identifying
all of the various sources of influence is quite difficult. Therefore, it is not surpris-
ing that different disciplines are devoted to the study of human behavior. Human
sexual behavior is no different. In Chapter 1, various perspectives were discussed
that shape the study of human sexual behavior. These perspectives cross several
different disciplines including the biological, psychosocial, behavioral, clinical,
and sociological, with an emphasis on anthropological factors in the explana-
tion of sexual behavior. All of these perspectives are important to developing a
thorough understanding of the various forces and factors that influence sexual
behavior and the many different viewpoints that must be considered.
In this chapter we present an in-depth discussion of the anthropological
perspective. Further, anthropology is contrasted with the disciplines of biol-
ogy, sociology, and psychology in order to highlight its unique contribution to
the study of human sexuality. In addition, key sexological terms and defini-
tions are presented.
Anthropological Perspectives in Contrast

Because of its interdisciplinary nature, the anthropological perspective in-
corporates psychological, sociological, and biological views into a holistic
Bio-Psycho-Cultural Approaches 21
approach. Holism is defined as an all-embracing outlook that “refers to the
study of the whole of the human condition; past, present, and future; biology,
society, language and culture” (Kottak, 2002: 4). Because of its interdisciplin-
ary nature, the anthropological approach incorporates psychological, sociolog-
ical, and biological views but is not limited to any one viewpoint. It is precisely
because of anthropology’s interdisciplinary nature and its holistic approach
with its interest in spanning great periods of time and vast distances, that it
includes but varies from the strictly biological, sociological, and psychological
approaches to human sexuality. These latter approaches tend to emphasize
contemporary twenty-first-century Euro-United States sexuality and to focus
on only one dimension (i.e., the biological, sociological, or psychological). For
anthropology, our scope is all of humankind. We study and compare a wide
range of peoples and societies from the ancient to the contemporary whose
technologies vary from simple to complex, along multiple dimensions includ-
ing the biological, psychological, and the socio-cultural.
Biological
The biological perspective focuses on the physiological basis of sexual behav-
ior. Biological perspectives on human sexuality stress what are referred to as
essentialist views of human sexuality. Essentialist views look at instinct as an
“essential” attribute of sexuality and regard reproduction as the core of that in-
stinct. Katchadourian and Lunde (1975: 2–3) have challenged this perspective
of human sexuality and counter that:
The incentive is in the act itself, rather than in its possible consequences
[reproduction]. Sexual behavior in this sense arises from a psychological
“drive,” associated with sensory pleasure, and its reproductive conse-
quences are a by-product (though a vital one)… [O]ur sexual behavior in-
volves certain physical “givens,” including sex organs, hormones, intricate
networks of nerves, and brain centers.
To reduce human sexuality to an instinct to reproduce ignores the importance

of other variables such as symbolic, cognitive, and affective factors in moti-
vating sexual behaviors. In addition, such a perspective ignores the role of the
group and shared cultural meanings in the survival of the species.
The biological view is, however, important for our understanding of human
sexuality. As females and males, the physiology of our sex (and this is far more
complex and continuous than might be expected) serves as the basis for our
discussion of the endocrinology and anatomy of sex in Chapters 4–6, but even
these biological features must be placed in a cultural context. For example, we
might ask if the sexual cycle of people in the United States, which is believed
to peak in males around eighteen or nineteen years of age and in females be-
tween the ages thirty-five and forty, is not shaped by cultural factors. Evidence
suggests that this is the case (see Hyde, 1982: 342, 353). The perspective of
22 Bio-Psycho-Cultural Approaches
anthropology is one that regards biology and culture as tandem developments
in human history. Anthropology emphasizes the importance of cultural sys-
tems and learning as central features in human evolution.
Sociological
The sociological tradition in sexual science is characterized by research that
focuses on contemporary sexuality in Europe and the United States and/or
usually emphasizes industrialized nations. It looks at the importance of “social
learning, social rules and role playing” in the expression of human sexual-
ity (Musaph, 1978: 84), and stresses patterns of social interaction. The survey
method remains the most popular sociological research technique used for
collecting sexological data (Katchadourian, 1985: 11). Sociological research
has provided a valuable contribution to sexology through its attention to the
intersection of class, status group, and the sexual experience. This approach is
evident in such classic works as Komarovsky’s Blue Collar Marriage (1962) and
Rubin’s Worlds of Pain (1976).
Anthropology and sociology are very compatible perspectives. There are,
in fact, a number of anthropologists whose sexological interests are primarily
in studying US culture. The anthropologist, in contrast to the sociologist, is
trained to maintain a comparative and bio-cultural view with reference to
the cross-cultural record regardless of the research topic; whether it is study-
ing childbirth or middle-aged women (Brown and Kerns, 1985; Jordan, 1993;
Trevathan, 1987). Although the sociological perspective tends to focus on the
importance of social structure and patterns of interaction, the anthropological
one additionally integrates the significance of beliefs in understanding human
behavior. This is essential in overcoming our own industrial society’s cultural
biases about sex that can creep into research. It is therefore useful in the study
of sexology in the United States to sustain a broader frame of reference includ-
ing structure, meaning, and cultural variation internally and cross-culturally.
For the anthropologist, this may also include an evolutionary understanding as
well. Generally speaking, however, anthropology and sociology are very closely
related disciplines and it is often impossible to distinguish between the works
of anthropologists and sociologists.
Psychological
Psychology addresses sexuality from the perspective of the individual and the
individual’s environment. In general, psychology’s approach to sexuality fo-
cuses on the motives behind sexual behavior and factors that influence that
motivation. To understand this process, psychologists study many different
facets of the human experience. Indeed, there is perhaps no one psychological
perspective, but several different thrusts within a general concern with cog-
nitive, emotional, behavioral, and some physiological components of human
sexuality.
On the theoretical level, psychologists have approached human sexuality
from many different angles. Some rather infamous theories within psychology
have focused on the critical role of sexuality in the development of personal-
ity. Freud’s rather complex theory proposes that the sex instinct (eros) along
with the death instinct (thanatos) were driving forces in the development of
an individual’s personality (Hyde, 1982: 6). Thus, Freud places biology at the
root of the individual’s psychosexuality. Developmental aspects of sexuality are
considered part of our physiological inheritance. As individuals develop, they
encounter various stages in which sexuality and conflict are characteristic and
shape the personality that individuals will have as adults.
Other theories, such as social learning theory (Bandura, 1986), emphasize
the role of observational learning in the acquisition of behavior. From this per-
spective, other people serve as models (e.g., a parent, friend, or a person in the
media) that help us to learn what behaviors are acceptable and unacceptable
in our society. When we see these models rewarded for their behaviors, we are
more likely to behave like the model and when we see the models punished for
their behavior, we are less likely to behave like the model. For example, social
learning has a powerful role in shaping our gender roles. In US culture, females
and males learn to present themselves in specific ways to be accepted and val-
ued. These lessons are learned from many different sources from an early age
onward. These models include parents, teachers, the media, and peers. Even
Halloween costumes serve to reinforce these roles. Boys are traditionally dressed
in action-oriented outfits that emphasize violence and death. Girls, on the other
hand, are dressed as brides and princesses and when they are presented as vil-
lains, they are eroticized—even at the ages of six and seven (Nelson, 2000).
In addition to theories important to human sexual behavior, psychology
researchers are also interested in the impact of individuals and their envi-
ronments on other aspects of sexual functioning. For example, research on
the male sex hormone testosterone is an interesting case. Research in this
area has found that numerous situational factors are related to changes in the
levels of testosterone in males. Males who have lost a competition, whether
physical or mental, (Mazur, Booth, and Dabbs, 1992), whose sports teams
have lost (Fielden, Lutter, and Dabbs as cited in Mazur and Booth, 1998), and
who have been degraded in the context of a military officer training program
(Thompson, Dabbs, and Friday, 1990) show decreases in their testosterone
levels. These relationships suggest a reciprocal relationship between societal
or cultural events and biological responses and highlight the importance of
socio-cultural variables to physiological functions.
Developmental psychologists are interested in the relationship of aging and hu-
man sexuality. The number of processes involved in the development of an indi-
vidual’s sexuality across childhood, adolescence, early and late adulthood is quite
large. For example, researchers have studied the influence of parents and peers
on adolescents’ sexual activity. Others have looked at the effectiveness of school
sex education courses on the initiation of sexual activity and the use of safer sex
behaviors. Still others investigate the motivation behind sexual infidelity.
Social and personality psychologists are interested in the significance of
variables associated with the person (e.g., religious attitudes, self-esteem, mood,
love for one’s partner) and the environment (e.g., the media, perceived friends’
behavior, attractiveness of the partner) in understanding sexual motivation
and behavior. One major area of study for these psychologists is intimate rela-
tionships. For example, research on the initiation of relationships shows that
some of the most important variables in attraction are physical attractiveness,
similarity, and physical proximity. Other research focuses on the dynamics of
relationships and factors that influence whether individuals will stay or leave a
relationship. Another area of relationship research deals with the darker side
of relationships—violence and jealousy. Finally, other researchers in this area
study the impact of erotica and pornography on perceptions of partners and
violence against women.
Another area of psychology deals with the study and treatment of sexual
dysfunction and “pathologies.” Research in this area is devoted to uncovering
the various explanations for sexual difficulties and finding effective means of
treating those difficulties. The goal of these treatments is to help those with
difficulties to function more effectively. For those whose behavior is consid-
ered undesirable or unwanted or detrimental to society, such as rapists and
pedophiles, the goal is to shape the behavior so that it no longer harms other
members of society.
As you can see, the scope of psychological studies covers extensive areas,
including sexual motivation, familial and peer influence, self-esteem issues,
and a number of other subject areas as far ranging as gender identity and
gender differences in sexual response. Although the topics may vary, the
approach is usually focused on the psychology of the individual and his/
her environment in the development of sexuality. The predominant trend
in psychology is to focus on a far smaller or micro-level analysis than that
undertaken by anthropologists. Though psychological anthropologists may
be interested in the mental and emotional structures behind the expression
of human sexuality in individuals, the cultural context remains an import-
ant feature for their analysis. Psychological anthropologists specifically, and
anthropologists generally, are more likely to be interested in the impact of
culture on family dynamics, childrearing practices, or in the cultural pat-
terning of sexual dysfunction within society. For example, the psychological
perspective locates dysfunction within the individual and the family milieu,
in contrast to an anthropological perspective which locates its source in soci-
ety. Like anthropology, psychology emphasizes the role of learning; however,
unlike anthropology it does not usually consider it within a cross-cultural
framework. Nor does it emphasize a culture’s childrearing practices, which
can influence adult personality (Katchadourian, 1985: 11; Kottak, 2002: 21).
A relatively recent point of connection between psychology and anthropol-
ogy has been the increasing popularity of evolutionary perspectives in psy-
chology, a major theoretical perspective often taken in anthropology (see
Chapter 3 for further discussion).
Interdisciplinary Approaches
Hopefully, by this point, it is clear that while each discipline views and inves-
tigates sexuality with a different focus, each contributes to a more complete
understanding of the behavior. The case of studying the issues associated with
sexuality and aging is illustrative of this point. A biologist might address the
developmental process of aging by studying the impact of elevated or reduced
levels of hormonal changes on the different sexual organs at adolescence and
old age. A sociologist might look at different types of sexual behaviors that
are expressed at different ages—childhood, adolescence, adulthood and late
adulthood—and how these differ as a function of race and class. A psychol-
ogist might study the impact of aging on the individual’s perception of their
sexual attractiveness to others and an anthropologist might question the evo-
lutionary advantage of sexuality at the various stages of the life cycle and how
different cultures might respond to these behaviors. All of these points are
important aspects of the relationship between aging and sexuality.
Not only do the different perspectives provide different pieces to the puzzle
that is human behavior, they also often enjoy a certain amount of “cross-
pollination.” There are scientists who are trained as physical anthropologists,
social psychologists, and psychological anthropologists. In other words, often
scientists are interested in the crossover of information from one discipline
to another. The physical anthropologist must be knowledgeable about both
anatomy and anthropology, the social psychologist looks at the intersection
of sociology and psychology, and the psychological anthropologist studies
the influence of culture on psychological phenomena. Therefore, it is often
difficult at times to determine what the perspective of the researcher might
be. Imagine that you have read about research that was conducted on the
occurrence of violence in dating relationships. In this study, the research
looked at variables such as the impact of personality (e.g., self-esteem, neurot-
icism, the willingness to trust others) and the environment (e.g., your part-
ner’s level of aggression) on the use of aggression. In addition, they report on
the prevalence of the behavior and how males and females differ in its use.
What would the perspective of that researcher be? What if you also find out
that his/her colleagues have looked at whether the rates of aggression differ
across regions of this country? Would you assume that the researcher was a
sociologist, a psychologist, or an anthropologist? Actually, the research men-
tioned here was done by social psychologists (Hammock, 2003; White and
Koss, 1991).
As you can see, it is often difficult to imagine what the perspective of
the researcher might be. Is the person who studies the influence of social
class, cultural norms, and beliefs about women on the incidence of date rape
a psychologist, a sociologist, or an anthropologist? Is the researcher study-
ing safer sex behavior in sex workers a sociologist or an anthropologist? Is
the researcher investigating the impact of the family on the use of violence
in intimate relationships a psychologist or sociologist? Is the work on the
supportive function of transgender support groups on transgender commu-
nities conducted by an anthropologist, sociologist, or psychologist? In other
words, the borders between the different disciplines and their perspectives
are often fuzzy and allow for a great deal of sharing of interdisciplinary re-
search to be conducted.
Similarly, you often find that teams of researchers representing different per-
spectives often come together to conduct research on sexual behavior. A classic

article on romantic love provides an excellent case in point. In this study, the
researchers studied different regions of the brain to determine whether areas of
the brain associated with reward and motivation systems are related to reports
of being intensely in love with a romantic partner. The study used MRI images
taken while the participants were looking at a picture of the beloved and of a
familiar individual. Their results support the relationship of love with certain
regions of the brain. Further, their research argues that romantic love is quite
complex and might actually be a motivational state that leads to specific types
of emotions and a focusing on the beloved (Aron et al., 2005). This fascinating
research was accomplished by a team of individuals trained as psychologists,
anthropologists, and neurologists.
The bottom line is that all of the different disciplines are critical to obtain-
ing a complete understanding of human sexuality. Though the primary focus
of this book is on the anthropological perspective, in the following chapters
you will see how each of these perspectives has contributed to the topics stud-
ied. This will result in a biological, psychological, and cultural approach that
examines how biological, psychological, and cultural variables influence sex-
ual behavior. But before we can look at individual behaviors, several critical
terms and theories must be understood.
Anthropological Concepts
Having compared and contrasted the anthropological perspective with
biological, sociological, and psychological ones, specific concepts from an-
thropology must be introduced to help further the understanding of the
anthropological approach to human sexuality. We have selected four key
terms and related concepts that will be useful. These are evolution, the cul-
ture concept, ethnocentrism, and cultural relativism. We have been very
selective in our choice of these four terms; there are numerous others that
are important in anthropological approaches to human sexuality. These are
introduced in subsequent chapters and may be found in the glossary at the
end of the text. Anthropological terms and concepts are discussed in greater
depth than other terms because of their importance. Other anthropological
terms of particular relevance for understanding the perspective of this text-
book are society, primates, bonding, ethnological, ethnographic, compara-
tive, cross-cultural, and genetic fitness. These are presented in the glossary at
the end of the text and/or are interspersed throughout the various chapters
of this book.
Evolution
The modern theory of evolution challenged the prevailing view of the sev-
enteenth and eighteenth centuries that all species were separate and divine
creations. Through his famous travels on the HMS Beagle, Charles Darwin
formulated his theory of natural selection. Naturalist Alfred Russell Wallace,
during this same period, independently arrived at a similar conclusion: spe-
cies are not separate creations but have evolved through a process of natural
selection. In 1858 Darwin and Wallace together rocked the meetings of the
Linnaean Society of London, and in 1859 Darwin published The Origin of
Species, documenting and detailing the theory of natural selection (Ember,
Ember, and Peregrine, 2005).
The central tenets of natural selection are straightforward. Natural selec-
tion is a mechanism of evolution that involves long periods of time. Those
individuals who are better adapted to their environments will be more likely
to reproduce surviving offspring than those who are not. Those individuals
who reproduce themselves are more likely to pass on the traits they possess
than those who are not so well adapted to their environments. This has been
referred to as survival of the fit and is calculated in terms of reproduction,
not life span of the individual. Since environments do not remain stable over
time, different characteristics may emerge as more adaptive so that what was
adaptive in one environment at one time is no longer adaptive at another
time. Adaptation is defined as “a process by which organisms achieve a bene-
ficial adjustment to an available environment, and the results of that process”
(Haviland, 1989: 59).
Though Darwin knew that traits were inherited, he could not explain how
new variation in populations occurred. It was Gregor Mendel, an Austrian
monk, who pioneered the study of genetics. His findings were incorporated
into the theories of the scientific community in the early 1900s. Studies of
genetics are now an essential component in the study of evolution (Ember,
Ember, and Peregrine, 2005).
The Culture Concept

The culture concept was developed at the end of the nineteenth century. Sir
Edward Burnett Tylor, considered the parent of anthropology, provided the
first clear definition. In 1897 he defined culture as “that complex whole which
includes the knowledge, belief, art, morals, law, custom and any other capa-
bilities and habits acquired by man… [and woman]… as a member of society.”
By 1952 Kroeber and Kluckhohn, in reviewing the anthropological literature,
found 164 different definitions of culture (Lett, 1987: 54–55).
With so many definitions available for the culture concept, we will be using
the following definition by Boyd and Richerson (1989: 28) for the purpose of
this book: “[Culture is the ]… information—skills, attitudes, beliefs, values—
capable of affecting individual’s behavior, which they acquire from others by
teaching, imitation, and other forms of social learning.” We have selected
this definition because of its thrust on the mental or cognitive dimension of
culture (i.e., what an individual knows, both consciously and unconsciously,
about her or his culture). This aspect, borrowing from a linguistic model of
language in anthropology, may be thought of as competence. It is all the rules
you need to know to act like a native of “x” group. Spradley (1987: 17) calls this
“cultural knowledge” and notes that it has two dimensions: explicit and tacit.
Explicit culture is the knowledge we can easily communicate about; for exam-
ple, knowing what our genealogies are or that we practice monogamy, albeit
serial, in our marriage systems. Tacit culture is “outside our awareness.” Hall’s
classic work on nonverbal communication, The Hidden Dimension (1966), has
described a number of spatially oriented rules about how close to stand next
to someone and when to touch or not touch that are examples of tacit culture.
We tend to be aware of these rules only when they are violated (Spradley, 1987:
22–24) as in the case of when someone “violates your space” or “gets in your
face.”
But culture is not just floating around in our heads; culture is behavior too.
It includes performance, our socially acquired life ways and our patterned in-
teractions, the things humans do and make. For the most part, it can be ob-
served, and this is what makes research into sex so difficult. Human sexuality,
except in certain cases of public and ritualized religious events, is private and
not readily observable. In order to understand observable patterns of behavior
or performance we need to know about competence, the values and beliefs
underlying the behaviors.
Anthropologists have defined certain characteristics:
• Culture is shared in that it is composed of a group of people who experi-

ence a common culture, although they need not embrace all the attributes
of the culture.
• Culture is learned and transmitted. The process of learning one’s culture
in a society is called “enculturation” (Ember, Ember, and Peregrine, 2005).
• Culture is symbolic. Thus, culture can be seen as the making of meaning
where meaning is arbitrarily assigned to behaviors, events, and the world
in general.
Related to the issue of cultural meanings are two additional concepts incor-
porated by anthropologists in their research on culture and sexuality; these
are emic and etic perspectives. Emic approaches take the perspective of the
participant’s point of view, seeing the world from the standpoint of the in-
sider. Ethnographers are dedicated to acquiring this emic perspective, before
they can undertake an etic analysis. Etic perspectives are those based on a
scientific outsider’s ways of knowing and understanding the world. This in-
cludes a “set of epistemological and theoretical principles and methodologies
acquired during a more or less rigorous and lengthy training period” (Harris,
1999: 33).
Ethnocentrism
According to Bernstein (1983: 183), ethnocentrism is “unreflectively imposing
alien standards of judgment and thereby missing the point of the meaning of
a practice.” It is “the attitude that other societies’ customs and ideas can be
judged in the context of one’s own culture” (Ember and Ember, 1990: 510)
and “that one’s own culture is superior in every way to all others” (Haviland,
1989: 296). As a discipline, anthropology has rejected this view as a result
of the method of participant-observation; early on anthropologists came to
know that “savages” were as human as those peoples living in industrialized
societies and that their behavior could only be understood as part of their cul-
ture (Haviland, 1989: 296). To fully comprehend the meaning and danger of
ethnocentrism, it is important to adopt the anthropological stance of cultural
relativism.
Cultural Relativism
According to Ember and Ember (1990: 510), relativism is “the attitude that a
society’s customs and ideas should be viewed within the context of that society’s
problems and opportunities.” Thus, “there is no single scale of values applicable
to all societies” (Winick, 1970: 454). Anthropologists find it crucial to remain
relativistic in order to describe, explain, and to discover meaning without the
biases of their home society. For example, it is obvious that US cultural biases
against homosexuality could impact scientific understanding of the subject.
Herdt (1981, 1987, 1988, 2006) and Williams (1986) have written about tribal
people’s homosexual practices and Blackwood (1984a, b, 2005a, b) on indige-
nous lesbian behavior. They offer a relativistic and nonjudgmental view of the
subject. It is evident from their writings that even terminology such as “homo-
sexual” and “lesbian” are so loaded and culturally specific that they cannot be
directly translated into the meaning given to, for example, boy-inseminating
rites among Sambia of Highland New Guinea (Herdt, 1987, 2006 among oth-
ers). The “homosexual” behavior of these peoples is simply not commensurable
with our Euro-American concept of homosexuality or gay (Herdt, 2006).
At some point in adopting a culturally relativistic perspective, you might
be faced with a clash of values. How far to take cultural relativism and where
to draw the line are questions often asked by students; however, it is one that
concerns anthropologists as well. In fact, Ethos, the journal of the Society for
Psychological Anthropology, devoted an entire issue to the question of moral
relativism (1990: 131–223). The introduction begins with:
What sort of theory of human values can be devised which encompasses

and accords legitimacy to the obvious cultural and historical diversity in
moral systems, without being so open that “anything goes”? That is a core
problem of moral (ethical) relativism….
(Fiske and Mason, 1990: 131)
As we live in an ever-shrinking world, cultural differences are increasingly
apparent through tourism, immigration, international education, the Internet,
and a host of other issues that bring moral relativism into play. These issues are
significant particularly around topics directly affecting the lives of college-age
students. Often it is easier to be relativistic regarding behavior or beliefs of
people geographically or even temporally distant. Both Bolin and Whele-
han maintain a stance that it is more difficult to be relativistic in one’s own
culture, especially when encountering non-normative behaviors and values
that vary from the ideals of the US middle class that currently dominate US
ideological systems. For example, homosexuality is only one of several possibil-
ities for sexual orientations, yet in several areas of the southern United States
these sexual practices were considered illegal and participants were prosecuted
under ethnocentric and inhumane laws. On June 26, 2003, in Lawrence &
Garner v. State of Texas, the US Supreme Court ruled 6–3 that sodomy laws
are unconstitutional and unenforceable when applied to noncommercial con-
senting adults in private (Sodomy Laws, 2006).
But what about other behaviors such as incest, rape, or abortion? Does a cul-
turally relativistic stance mandate that these are acceptable? No, it does not.
Rape and incest are most clearly “crimes” in the industrialized society’s view.
Abortion, though, presents something of a quandary. Once a crime, abortion
now is considered a choice by the individual until that legally granted choice
is removed. Where you draw the line is ultimately your decision on many of
these issues. While you may choose to take the stance that it is an individu-
al’s choice on abortion, others may find this problematic and challenge you.
In the case of rape and in most incest situations, the participants are clearly
victims of crimes and have no choice. In keeping with a feminist perspective
on the abortion issue, we take the position that it is the right of the woman
to choose. Cultural relativism does not require that you agree with or like a
certain behavior or belief system. Rather, it requires that you are able to sus-
pend judgment and place that behavior or belief system within the context of
the culture in which it is found. Cultural relativism is therefore a method and
an approach to the world that asks that you temporarily suspend judgment. It
does not demand that you forsake all values or beliefs in human rights. “Thus,
after an understanding generated by a culturally relativistic stance may come
an ethical positioning which for many of us includes a humanistic concern for
all human rights” (Basirico and Bolin, 2000: 88).
Definitions of Human Sexuality

So how do you define human sexuality? We turn now to this definition. In
keeping with the anthropological perspective, human sexuality should be
viewed through a wide lens and understood from a relativistic perspective. De-
fining human sexuality is no simple task. It is impossible to set narrow bound-
aries for what is included within the category we call sex.
Katchadourian (1979: 8–34) has described the many meanings of the word
“sex.” According to Katchadourian’s research, the English word, derived from
the Latin sexus, can be traced back to the fourteenth century (1979: 9). The
term “sex” has undergone a variety of permutations and grammatical uses in
popular culture over time in US society. Sex commonly refers to what peo-
ple “do,” is usually termed “sexual behavior,” and often is described as erotic
(Katchadourian, 1979: 11). Barale (1986) offers a down-to-earth definition:
“Genitals are the given: what we do with them is a matter of creative inven-
tion; how we interpret what we do with them is what we call sexuality” (in
Duggan, 1990: 95). Sometimes the term “sex” is used by researchers in place of
gender to refer to embodiment or physical bodies. For example, at some point
in their lives most adults in industrialized nations will be asked to check a
box on a form that asks them their sex, male or female. In the Euro-American
gender schema (model of the world) sex typically refers to biological attri-
butes including chromosomes, external genitals, gonads, internal reproductive
structures, hormonal states, and secondary sexual characteristics, among oth-
ers. Gender may be defined as the psychological, social, and cultural aspects of
being a male or female. Gender is a cultural construction and system of mean-
ings with multiple dimensions including gender identity, one’s sense of self and
awareness as a woman, man, boy, or girl, to greater or lesser degrees, and/or
as an additional or in-between gender (Bolin, 1996b: 24) (see Chapter 15 for
further discussion of gender identity and gender roles).
Time and Space

Definitions of human sexuality have varied across time and space. Human
sexuality is symbolic behavior as much as it is reproductive behavior. Sex in-
cludes self-stimulation (masturbation) as well as copulation and other activi-
ties related to coitus. It also includes noncoitally oriented pleasuring as well
as sex between partners of the same sex. Questions of where the boundaries
are and what to include in the definition of sex are difficult. For example,
Katchadourian asks if sexual fantasy can be included in the definition of sex?
It is certainly erotic, “but is it ‘behavior’” (1979: 11)? Others have attempted to
avoid the problems of behavior and emotional arousal by using the term “sex-
ual experience.” When this array of terms is placed in the even wider context
of the cross-cultural record, we are led to ask if there are indeed any sexual
universals amidst such a wide range of human sexual expression.
For the purposes of this chapter, we have taken the broadest possible scope to
explore the many meanings of sex including species-wide behavior, biological,
social scientific including behavioral, cognitive, and affective, and socio-cultural
definitions and dimensions. Other attributes, such as the functions of sexuality
in the cultural context, will be included. Contributing to the complexity of the
definitional task is that sexual expression may be part of actual behavior or may
be purely symbolic. Sexuality may also be expressed in terms of the metaphorical
as is often found in rituals. For example, among the Ndembu as studied by Turner
(1969: 10–43; Cohen and Eames, 1982: 250–251), the Isoma fertility ritual is rich
with sexual symbolism. In one part of this ritual the infertile woman holds a
white chicken, which represents semen and good fortune in Ndembu cosmology.
Definitions of human sexuality do not remain stable over time, as is doc-
umented by the history of Euro-American views of sexuality in the field of
sexual science. Scientific studies have shifted their interests from sex as re-
production to perspectives that focus on sexuality and its nonreproductive
aspects, including larger issues such as gender variance (Jacobs and Roberts,
1989: 439–444). Medical views have fluctuated in tandem with changes in the
wider culture. Thus, the well-known prudish and sexually repressive cultural
atmosphere of “mainstream” (i.e., middle class) Victorianism in the period of
mid-1800s–1900s was reproduced in medical views so that masturbation was
believed to cause mental illness (Masters, Johnson, and Kolodny, 1982: 11–12).
The following quotation illustrates all too clearly the Victorian discourse on
female sexuality. We quote from Ruth Smythers’ (1989 [1894]) “Instruction and
Advice for the Young Bride on the Conduct and Procedures of the Intimate
and Personal Relationship of the Marriage State.”
To the sensitive young woman who has had benefits of proper upbringing,
the wedding day is ironically, both the happiest and most terrifying day of
her life… On the negative side, there is the wedding night, during which
the bride must pay the piper, so to speak, by facing for the first time the expe-
rience of sex. At this point, dear reader, let me concede one shocking truth.
Some young women actually anticipate the wedding night with curiosity
and pleasure! Beware of such an attitude. A selfish and sensual husband can
easily take advantage of such a bride. One cardinal rule of marriage should
never be forgotten: GIVE LITTLE, GIVE SELDOM, AND ABOVE
ALL, GIVE GRUDGINGY… while sex is at best revolting and at worst
rather painful, it has to be endured, and has been by women since the be-
ginning of time, and is compensated for by the monogamous home and the
children produced through it.
(1989 [1894]: 5–7, emphasis author’s)
This historical view represents a fundamental change over time in how sex is
regarded for women. In the United States today the model of sex is one of “sex
as pleasure” rather than sex as duty.
Despite this new model, there still exists a double standard in US society
wherein a woman’s sexuality is bounded by a model of sexuality that empha-
sizes monogamous, committed heterosexual and potentially reproductive sex.
Such changes in attitude influence how human sexuality is experienced and
integrated within culture.
Species-Wide Behavior
Human sexuality, or more accurately the capacity for sexuality, is a species-wide
behavior. The term species is defined as “a population or group of populations
that is capable of interbreeding, but that is reproductively isolated from other
such populations” (Haviland, 1989: 66). Although all humans may mate with
one another, it is characteristic of cultures to restrict sexual and reproductive
activities between people. Sometimes the cultural meaning assigned to cer-
tain gene pools and/or physical attributes prohibits groups of humans from
interbreeding with one another even though they are perfectly able to do so
(Haviland, 1989: 66). Thus, all humans are capable of interbreeding and pro-
ducing viable offspring, but cultural barriers may prevent people from marry-
ing and reproducing.
Biological Definitions and Dimensions

Biological definitions include sex in reference to “the two divisions of organic
beings identified as male and female and to the qualities that distinguish males
and females” (Katchadourian, 1979: 9). This is frequently termed biological
sex, yet this definition is problematic as well as ethnocentric. Relying on a
model described by Money and Ehrhardt (1972: 4–15) and expanded upon in
Bolin and Whelehan’s undergraduate classes, we offer a multifaceted view of
biological sex that challenges the simplicity of the notion of defining one’s sex
as either male and female. How, in fact, do we reach that determination? How
do you know what sex you are? Our list of sex attributes includes chromosomal
sex; gonadal sex; hormonal (endocrine) sex; sex of internal reproductive struc-
tures in addition to the gonads;, secondary sexual characteristics (including
distribution of fatty tissues, hair growth, breast development); gender identity
(self-perception as male or female); gender role; sex of assignment and rearing;
and legal sex among others.
One can easily see how the biological can be mixed up with the cultural
when the discussion turns to gender roles and legal sex. Yet, strictly biological
determinants like hormones, secondary sexual characteristics, internal and
external reproductive features are not so clear either. Biological sex exists on
a continuum. There are a number of gender variations that illustrate this con-
tinuum in biological sex (Fausto-Sterling, 2000; Kessler, 2004; Masters, John-
son, and Kolodny, 1982: 504).
In testicular feminizing syndrome, the male fetus with androgen-
insensitivity syndrome produces enough testosterone, but because of a genetic
problem it cannot be absorbed and processed. As a consequence, the fetus de-
velops a blind vagina (it doesn’t lead to a uterus) and female genitalia. At birth,
the infant looks female but does not have the internal female reproductive
organs and is usually identified as a girl. At puberty, the individual develops
breasts but cannot menstruate and is infertile (Blackless, et al., 2000: 153–154;
Money and Ehrhardt, 1972: 280).
To suggest to such a young woman at puberty that because her chromo-
somes and hormones are male that she is a man overlooks the fact that gen-
der is a lived phenomenon (Kessler and McKenna, 1978: 76–77; Ward and
Edelstein, 2006: 169–192). In US society two choices exist: female or male.
The androgen-insensitive male is reared as a female, and usually has a gender
identity as a woman. In a socio-cultural sense, she is a woman, although she
may not be a physiological female. From a physiological perspective, she is an
intersex person because she has both male and female characteristics; xy chro-
mosome structure, female genitals, and undescended or partially descended
testes (Intersex Society of North America).
Not only are there individuals who are biologically intersex, but other so-
cieties may recognize more than two genders as well. In some cultures, gender
may be an achieved (acquired) rather than an ascribed (assigned) status. The
cross-cultural record reveals all these possibilities. Anthropologists have long
reported on the existence of societies with more than two genders referred to
as gender transformed statuses, alternative genders, supernumerary genders,
gender variant persons, and two spirits among other terms1 (e.g., Bolin, 1996b:
27–30; Jacobs, 1994; Martin and Voorhies, 1975: 94). It now appears that a
variety of kinds of behaviors and variations in gender expression have been
lumped under these terms. For example, the two spirit has been referred to as
a gender-transformed status, as an alternative gender, and/or as a cross-gender
role. Nevertheless, this identity may generally be described as a position in so-
ciety in which a person takes on some or all of the tasks, dress, and behaviors
of the other gender. Rather than just two genders as in the Euro-American
case, the Mohave recognized four genders: woman; hwami (female two spirit);
man; and alyha (male two spirit). The Chuckchee reported seven genders,
three females and four males (Jacobs and Roberts, 1989: 439–440; Martin and
Voorhies, 1975: 96–99, 102–104).
The other biological definition of sex focuses on the physiology of sexual
arousal and coitus and on the reproductive biology of humans. This includes
changes in the human cycle in both reproductive physiology as well as hu-
man sexual response. As Jacobs and Roberts (1989: 441) so eloquently point
out: “reproduction and sexuality are codependent variables in the human life
cycle. But sex and sexuality are much more complex than linking them with
reproduction.”
Behavioral, Cognitive, and Affective Definitions and Dimensions

The social science perspectives broaden the study of human sexuality by look-
ing beyond the mechanics of sexual behavior to other factors, most notably
behavioral, cognitive, and affective factors, which influence sexual expression
and perception. The behavioral definitions of human sexuality focus on be-
haviors and consequences that can be both observed and measured. When
dealing with the cognitive dimensions of sexuality, yet another layer is added
to sexuality by considering how we think about, judge, rationalize, attribute,
and perceive sexual stimuli and behaviors. Finally, affective dimensions also
are considered by social scientists studying sexuality. Our emotional or affec-
tive responses add many dimensions to our experiences by influencing how
we interpret and view behavior. In this capacity, they can actually serve as
motivators of behavior, influencing who and what we are willing to accept and
approach.
The work of Kinsey and his colleagues represents one of the most well-known
behaviorist studies of human sexuality: Sexual Behavior in the Human Male
(1948) and Sexual Behavior in the Human Female (1953). The Kinsey reports
focused on six sexual outlets leading to orgasm (masturbation, sex dreams, pet-
ting, coitus, homosexuality, and sex with animals). They were based on inter-
views with 5,300 males and 5,940 females. Kinsey was central in the creation
of the scientific study of sex. He exemplified how such an emotionally charged
subject could be studied with scientific rigor. The Kinsey reports opened a
forum for the public discussion of human sexuality. Gagnon (1978: 93) believes
that the public furor created by this work ushered in “a major increase in the
publicly sexual character of society that occurred in the late 1960s and early
1970s.” Others have argued, however, that since the 1980s our society has also
experienced a backlash to these more liberal trends in sexual expression and
education (Faludi, 1991; Kusz, 2001). Indeed, the Kinsey Institute for Research
in Sex, Gender and Reproduction states: “the work is not done. And the stakes
today are higher than ever—HIV/AIDS, sexual problems, abuse—the need for
objective research and education has never been more urgent. Progress: Yes,
Job Done: No” (Kinsey Institute for Research in Sex, Gender, and Reproduc-
tion, 2006).
The behaviorist approach to sexuality is concerned with the scientifically
measurable (i.e., external states). Kinsey was critical of sex research done
through the single case method or the method of ethnographic sexology. He
advocated the sociological method of the survey of large populations with con-
cern for accurate representation and the “statistical sense” without which one
was “no scientist” (Gagnon, 1978: 93).
A behaviorist approach to sexuality provides important information about
what behaviors are being displayed, by whom, and with what frequency. But it
does little to explain why those behaviors are occurring and why some behav-
iors are more likely to occur than others. Further, it neglects the role that our
inner thoughts play in our behaviors. Why are we likely to engage in some be-
haviors than others? How do we perceive others’ actions and what we believe is
appropriate or inappropriate? What attracts us to some partners but not others?
A good example of the impact of cognitive factors on sexuality is sexual
scripts (Gagnon and Simon, 1973). According to this theory, we, as individuals,
conduct sexual encounters based on a script, just as if we were players in a the-
atrical production. In other words, our sexual encounters respond to a running
script in our minds which dictates what behaviors are appropriate, when they
are appropriate to display, and with whom it is appropriate to do them. These
learned scripts are likely to influence many different aspects of our sexual lives.
A recent study by Else-Quest, Hyde, and DeLamater (2005) looked at the im-
portance of the first sexual encounter and sexual scripts. They found that first
sexual encounters that occurred outside of contexts generally accepted for
sexual activity (i.e., prepubertal sexual experiences, forced sex with a blood
relative, sex for pay, or sex while impaired by alcohol or drugs) were linked to
negative consequences later in life such as more sexually transmitted diseases,
sexual dysfunction, more sexual guilt, and lower life satisfaction. Based on
these findings, they argue that those sexual encounters that violate accepted
sexual scripts have long-term repercussions for sexual functioning.
One of the reasons that sexual scripts become important is the emotional
responses that are a critical aspect of our sexual scripts. If shame or guilt be-
comes associated with sexual behavior it is not surprising that sexual difficul-
ties might arise in the future. This relationship points to the importance of
considering emotions or affect in the study of sexuality.
Affect can have a powerful impact on many different aspects of our sex-
uality. For example, in a number of societies, the transition into puberty is
often marked with a wide range of emotions from joy to shame. Attitudes
about certain groups, such as homophobia, are often accompanied by strong
emotional reactions. Sexual encounters with partners are often colored by
emotional responses such as trust, love, and liking. The potential impact of
affect on what might be considered the “dark side of relationships,” inflicting
of aggressive behaviors on your partner, can be seen in a study conducted by
Hammock (2003). This study investigated the ability of a number of variables
to predict the use of physical and psychological aggression in intimate rela-
tionships. Physically aggressive behaviors were actions that either threatened
or delivered physical harm (e.g., kicking, hitting, forcing sex, and choking).
Psychologically aggressive tactics involved those that potentially harmed the
self-concept of the recipient (e.g., calling the recipient names, giving angry
stares, isolating the recipient from friends and family, and humiliating or de-
grading the recipient). She found a number of variables reliably predicted the
use of the participant’s use of physical and psychologically harmful behaviors.
These variables involved love, trust, and emotional commitment. Not surpris-
ingly, those individuals who felt they could not trust their partner were more
likely to use both physical and psychological aggression with that partner. On
the other hand, those who reported high levels of love and commitment for
their partners were more likely to use physical and psychological aggression.
Though the last finding might seem surprising, an interesting explanation is
given. We are not likely to bother using aggressive behaviors with our partners
when the relationship is of little value to us – in other words, ones in which
we have little emotional commitment. However, when we have high levels of
emotional commitment, we might have a greater motive for controlling the
partner or for retaliating against the partner for things the partner says or
does. Certainly, this study suggests that emotional responses have interesting
impacts on relationships and what we are willing to do in them.
Socio-Cultural Definitions and Dimensions

As we have seen, biological definitions of human sexuality focus on anatomy
and physiology, physical development, and changes in human sexual response
throughout the life cycle with an emphasis on the reproductive. Biological defi-
nitions of human sexuality also include behavioral dimensions. The cognitive
and affective dimensions involve our interpretations of sexual experience and
behaviors. In contrast, socio-cultural definitions accent the role of customs in
shaping human behavior and tend to take a relativistic stance. This position
opposes the biological and behavioral definitions that look to physiology to
explain alleged sex differences in human response. Socio-cultural definitions
regard sexual behavior as culturally constituted and created (Gagnon, 1978:
95). Gender is a socio-cultural construct in which meanings are assigned to
biology. The sex-gender system is defined by Rubin (1975) as: “the set of ar-
rangements by which a society transforms biological sexuality into products of
human activity” (in Vance, 1983: 372).
Socio-cultural studies have gradually evolved from an early interest in sex as
reproduction (e.g., Martin and Voorhies’ Female of the Species, 1975) to studies
of sex as institutional (e.g., marriage systems) and finally to sexuality itself
(Jacobs and Roberts, 1989: 439; Lyons and Lyons, 2004).
Sex, Gender, Masculinity, and Femininity

In this section, we present a list of terms related to the concept and construct
of gender. It is important to define gender early in our discussion of masculinity
and femininity. Research conducted in the 1970s often intertwined and con-
flated the terms sex and gender, although by the early 1980s successful efforts
were made at separation and redefinition carried through to the new millen-
nium (Jacobs and Roberts, 1989: 439). Jacobs and Roberts (1989: 439) offer an
excellent definition:
Gender is the socio-cultural designation of bio-behavioral and psycho-

social qualities of the sexes; for example, woman (female), man (male),
other(s) [e.g., two spirit, see Chapter 13 for further discussion]. Notions of
gender are culturally specific and depend on the ways in which cultures
define and differentiate human (and other) potentials and possibilities.
Kessler and McKenna’s (1978: 7–16) definitions also serve us well. Though it
is conventional to define sex as the biological aspects of male or female, and
to define gender as the “psychological, social, and cultural aspects of maleness
and femaleness,” Kessler and McKenna argue that even the concept of two
biological sexes is a social construction (1978: 7).
For purposes of clarity, sex will be used in this context to refer to activi-
ties related to sexual pleasure, arousal, and intercourse whether recreational
or for reproduction (Jacobs and Roberts, 1989: 440). Gender will refer more
broadly to the cultural aspects of being male or female. Elsewhere, specific us-
ages such as chromosomal, hormonal, or morphological sex will be presented,
even though these biological characteristics are always interpreted through a
cultural lens (cf. Kessler and McKenna, 1978: 7).
Through an understanding of the “attribution process,” how people as-
sign gender to others, insight can be gained into the social construction of
femininity and masculinity. Euro-American femininity and masculinity are
integrated in a binary gender scheme whose central tenants are that there are
only two sexes, male and female, and that these are appropriately associated
with the two social statuses of gender: men and women, boys and girls. “What-
ever a woman does will somehow have the stamp of femininity on it, while
whatever a man does will likewise bear the imprint of masculinity” (Devor,
1989: vii). Therefore, masculinity and femininity are associated with gender
roles. The Euro-American gender schema is a shared belief system about sex
and gender. It regards biological sex as the basis for gender status, which is the
basis for gender role. The actual process whereby people attribute gender to an-
other actually occurs in the reverse to our gender schema; a person’s display of
masculinity or femininity (gender role) indicates gender, which is followed by
the presumption of appropriate genitalia which are not readily visible (Devor,
1989: 149; Kessler and McKenna, 1978: 1–7, 112–141). Without our portable
gene scanners and x-ray vision, daily life consists of encounters in which the
biological is clearly mediated by cultural expectation in the attribution pro-
cess. We do not really see genitals and sex, but gender presentations of femi-
nine and masculine beings.
In summary, masculinity and femininity may be defined as components of
gender roles that include cultural expectations about behaviors and appear-
ances associated with the status of man or woman in the industrial binary
model of the sexes. For the purposes of our discussion, the following definition
for gender role will be used:
Everything that a person says and does, to indicate to others or to the

self the degree in which one is male or female or ambivalent. It includes
but is not restricted to sexual arousal and response. Gender role is the
public expression of gender identity, and gender identity is the private of
experience of gender role… Gender identity… [is]… the sameness, unity,
and persistence of one’s individuality as male or female (or ambivalent),
in greater or lesser degree, especially as it is experienced in self-awareness
and behavior.
(Money and Ehrhardt, 1972: 284)
Because of the attribution process, gender roles are often confused with sex
and biology. Gender role stereotypes include ideas that differences in gender
are the result of biology. For example, women are more nurturing, men are
more aggressive, and women are emotional while men are rational. These dif-
ferences are rather the result of learned behaviors. Stereotypes such as these
are classified by sociologists as expressive and instrumental gender roles. Boys
are socialized into instrumental roles that are associated with acting or achiev-
ing while girls are socialized into relationship-oriented or expressive roles
(Renzetti and Curran, 2003: 167). That these roles are cultural and are not
natural is amply demonstrated in the cross-cultural record in which a diver-
sity of behaviors and expectations are recorded. Mead’s study of the Arapesh,
the Mundugumor, and the Tchambuli (they call themselves the Chambri) in
Sex and Temperament in Three Primitive Societies (1963 [1935]) offers a clas-
sical account of gender role variation in counterpoint to our industrialized
society’s conceptions. Among the Mundugumor, both men and women were
aggressive and non-emotional, while among the Arapesh, both sexes were co-
operative and nurturant. The Tchambuli (Chambri) expressed the reverse of
our Euro-American gender roles with cooperative caring men and assertive
women as the behavioral norm.
Deborah Gewertz’s research on the Chambri complicates Mead’s perspec-
tive with a regional and historical approach. During Mead’s research the
Chambri had only recently returned to their home site after a twenty-year
exile. Consequently, the men were focused on refurbishing their ritual equip-
ment and seemed to be highly involved in artistic and expressive endeavors.
The women appeared dominant to Mead because they had already estab-
lished their economic system of barter. Nonetheless, Gewertz argues that
Mead was essentially correct in her view that gender roles are flexible and
responsive to changing environments (Gewertz, 1981; Ward and Edelstein,
2006: 60–61).
Biology and Sex: Political Aspects

No definition of sexuality can be complete without viewing its political as-
pects. We conclude with the interface of politics of sexuality with biologi-
cal, behavioral, and socio-cultural definitions of sex. In 1978 Burnham stated:
“Whether the boundaries of women’s place in society were erected with the
bricks of theology or the cement of genetic determinism, the intention is that
the barriers shall remain strong and sturdy” (Burnham, 1978: 51). Burnham’s
statement provides a good introduction for our discussion of the politics of
biology and sex. Biological/sexual functions have been used to serve larger
political purposes in societies and ours is no exception. For example, women’s
role in reproduction has been interpreted to justify conceptions of female infe-
riority which support ideologies of gender inequality.
Nineteenth-century physicians maintained the view that for medical rea-
sons it was unhealthy for women to be educated. This was based on a medical
ideology that the brain and the reproductive organs shared the same biological
resources, so that development of one meant the other was deprived. Since
women’s role was defined as a reproductive one, feeding her brain through
education was seen as jeopardizing her reproductive capabilities (Burnham,
1978: 51–52).
Other researchers have described the historical relations of sexuality to
changes based on the expansion of industrial capitalism in developing and de-
veloped nations, thereby providing a political-economic interpretation (Ross
and Rapp, 1983: 51–73). Ross and Rapp (1983: 51) note that “the personal is
political” reflecting our point that what one may think of as private is also pub-
lic in the sense that it is linked with broader institutions of the industrial and
global political economy. These institutions are patriarchal and perpetuate
beliefs about the differences between the sexes and their respective sexuali-
ties. Such ideologies are then supported by a sexology in which androcentric
(male biased) views are legitimized as science, aided and abetted by biological
reductionism.
Sanday’s study of rape-prone societies clearly shows the relationship between
male dominance and political power. Rape-prone societies were found to glo-
rify strength, power, and violence and gave women no voice in the political
sphere or in religious life. Women were regarded as being “owned” by men in
such societies (Benderly, 1987: 187; Sanday, 2003). In this way, sexual behavior
is defined as violent and as natural for men. In opposition to the rape-prone
societies are the rape-free societies which challenge the essentialist view of
men as “naturally” aggressive. A society deemed rape-free was associated with
resource stability, the absence of competition, and egalitarian social structures
for men and women. Rather than a belief in a male supreme being, rape-free
societies acknowledged a male and female deity or a “universal womb” (Bend-
erly, 1987: 187–188; Sanday, 2003). These societies were identified by Sanday as
those where rape did not occur.
Some research suggests that as a result of the changes to the world’s societ-
ies due to colonialism, industrialization, and globalization, there are very few
societies remaining in which rape does not occur. An exception is Lepows-
ky’s (1993) ethnography of the New Guinea people of the island of Vanatinai.
This is an egalitarian decentralized matrilineal society which interrogates the
notion that the male subordination of women is inevitable. Lepowsky notes
“Physical violence again women—and men—is abhorred and occurs only
rarely today [in Vanatinai]. I have never heard of a case of rape” (Lepowsky,
1993: 292).
To understand culture change and the impact of colonialism and globaliza-
tion on sexuality, it is important to recognize the dynamic element of culture
and the role of culture change in human life. Humans have never lived iso-
lated lives, and culture contact between bands and tribes has probably existed
since humans began to populate the world 2 million years ago. Wolf (1982: ix)
argues: “Human populations construct their cultures in interaction with one
another, and not in isolation.”
The small-scale tribal world of autonomous decentralized, non-stratified so-
cieties as opposed to massively complex large-scale modern industrial states
was the only world until 7,500 years ago (Bodley, 2005: 10–11, 165). Accord-
ing to Bodley “This was the beginning of a global cultural transformation in
which very quickly a handful of ruling elites successfully constructed large,
complex chiefdoms, kingdoms, city-states and empires in favorable locations
worldwide” (2005: 165). By the 1600s, prior to the industrial revolution, a world
commercial system was already developing as a precursor to modern global
capitalism. From this time onward, commercial interests dominated extant
political systems, spanning colonization, industrialization, and the expansion
of modern nation states. A concomitant economic expansion resulted in the
increasing division between wealthy developed nations and developing na-
tions (Bodley, 2005: 341). This process is referred to as globalization, defined
as “the ongoing spread of goods, people, information and capital around the
world” (Ember, Ember, and Peregrine, 2005: 545). Consequently, indigenous
peoples have been drawn into a pervasive system of expanding global capital-
ism. Globalization has influenced the sex and gender systems of indigenous
populations and developing nations in diverse ways. And women’s status and
sexual autonomy have been particularly affected in negative ways inspiring
Ward and Edelstein (2006: 243) to remark that “women are the last and largest
colony on earth… We are ‘the Other.’” For further discussion of globalization
and sex see Chapter 17.
Anthropologists refer to the influence of culture change on indigenous peo-
ples as syncretism: the blending and mixing of indigenous cultural elements
with those introduced by other societies; that is, the “interplay of local, re-
gional, national and international cultural forces” (Kottak, 2002: 504). This
term highlights the indigenous response to the imposition of culture by exter-
nal sources. It illustrates that indigenous peoples are creative and resistant in
their response to efforts to assimilate and acculturate them and that globaliza-
tion is not a uniformly flat and hegemonic process.
Sexual Violence
Sexual violence—sexual activity that takes place without consent—is a long-
standing and ubiquitous part of human societies. The term refers to words
and actions of a sexual nature expressed against a person’s will and without
their consent, using force, threats, manipulation, or coercion (“About Sexual
Assault,” 2018, National Sexual Violence Resource Center, NSVRC). Consent
means saying “yes” to sexual activity; not saying “no” is not consent (wom-
enshealth.gov). Saying “yes” when you are legally unable to do so (e.g., under
threat, when you are physically or mentally unable to, or when you are under-
age) is also not consent (womenshealth.gov). Sexual violence is an umbrella
term that includes acts such as rape, sexual assault, sexual harassment, sexual
trafficking, masturbating in public, non-consensual image sharing, and watch-
ing someone engage in private acts without their knowledge or permission
(“About Sexual Assault,” 2018, National Sexual Violence Resource Center,
NSVRC). While some of these terms are used interchangeably in everyday
speech, the distinctions can illuminate the many forms of sexual violence that
take place on a daily basis. Familiarity with the definitions of these terms can
also help victims of sexual violence identify that a sexually violent act has
taken place. Here we will define two commonly used terms, sexual assault
and sexual harassment. We recognize that sexual violence is a global problem;
in our discussion, we use the conditions in the United States as an example.
We would also like to note that this section provides an overview, not an
in-depth analysis, of the meaning and prevalence of sexual violence in the
United States.
According to the US Department of Justice Office on Violence Against
Women (OVW), sexual assault “means any nonconsensual sexual act pro-
scribed by Federal, tribal, or State law, including when the victim lacks capac-
ity to consent” (justice.gov/ovw/sexual-assault). Sexual assault, then, includes
any type of sexual contact with someone who cannot or does not consent
(womenshealth.gov). While rape is commonly understood as a form of sexual
assault, many are unaware that acts like unwanted touching above or under
clothes, voyeurism, and unwanted “sexting” are also included (womenshealth.
gov). While legal definitions differ between states, sexual assault, by defini-
tion, is a crime. Sexual harassment is both a specific legal term that applies
to conduct in the workplace and at educational institutions, and a term with
a broader meaning in public discourse. In legal terms, sexual harassment is
a violation of Title VII of the Civil Rights Act of 1964 (EEOC). Title VII
states that:
Unwelcome sexual advances, requests for sexual favors, and other verbal
or physical conduct of a sexual nature constitutes sexual harassment when
submission to or rejection of this conduct explicitly or implicitly affects
an individual’s employment, unreasonably interferes with an individual’s
work performance or creates an intimidating, hostile or offensive work
environment.
Sexual harassment is also a violation of Title IX, a broad statute against sex-
based discrimination that applies to all educational institutions in the United
States that receive federal assistance (US Department of Education, Office for
Civil Rights). While these forms of sexual harassment are civil violations, they
are not criminal violations (Rape, Abuse & Incest National Network, RAINN).
So while sexually harassing a coworker by making unwelcome sexual advances
could lead to the harasser being fired, it could not, on its own merit, lead to
incarceration or a criminal record. Outside of the workplace and educational
settings, many forms of what is commonly referred to as sexual harassment are
not subjected to any form of regulation (e.g., unwanted catcalls, sexual jokes,
and sharing of sexual fantasies). Sexual harassment and sexual assault, then,
cover a broad range of offenses, all of which are a form of sexual violence.
Statistics from various studies show the extent to which sexual violence is a
problem in US society:
• Every seventy-three seconds a person is sexually assaulted.

• One in three women and one in four men have experienced sexual vio-
lence involving physical touch during their lifetimes.
• One in six women and one in thirty-three men have been the victim of
an attempted or completed rape in their lifetime.
• Ninety percent of rape victims are female.
• More than half (55 percent) of sexual assaults take place at or near the
victim’s home.
• One in three female rape victims and one in four male rape victims ex-
perienced it for the first time between ages eleven to seventeen. One in
eight female victims and one in four male victims experienced rape before
age ten.
• Rape costs $122,461 per victim, including medical costs, lost productiv-
ity, criminal justice activities, and other costs. This is in addition to the
emotional and mental cost of being assaulted (“Preventing Sexual Vio-
lence,” 2020, Centers for Disease Control and Prevention, CDC; “Scope
of the Problem: Statistics,” 2018, Rape, Abuse & Incest National Net-
work, RAINN).
Staggering as these numbers are, the rate of rape and sexual assault has fallen
by more than half since 1993, from a rate of 4.3 assaults per 1,000 people in
1993 to 1.2 per 1,000 in 2016 (“Scope of the Problem: Statistics,” 2018, Rape,
Abuse & Incest National Network, RAINN). Considering the number of
sexual assaults that go unreported, these numbers are unlikely entirely ac-
curate. Even so, they do suggest a decline over time (Finkelhor and Jones,
2012; Lankford, 2016: 44). Possible reasons to explain the decline include
increased awareness of and public support for civil rights, women’s rights,
gay rights, and children’s rights; the adoption of affirmative consent poli-
cies at institutions of higher education; less tolerance for sexual violence
and victim-blaming in popular culture; and improved technology that assists
law enforcement in catching offenders and helps prosecutors convict them
(Lankford, 2016: 45).
Although this trend is encouraging, the rates of sexual violence remains
high for many sections of the US population. Among undergraduates, for
instance, 22 percent report experiencing at least one instance of sexual
assault since starting college (Mellins et al., 2017). Among these, women
report a rate of 28 percent, gender non-conforming students a rate of 38
percent, and men a rate of 12.5 percent (Mellins et al., 2017). While women
in general are at risk for sexual assault, the risk is higher for multiracial
women (32 percent), Native American and Alaskan Native women (28
percent), and non-Hispanic African-American women (21 percent) (Black
et al., 2010).
In recent years, the ubiquity of sexual violence against women in partic-
ular has prompted a massive global protest under the banner of #MeToo.
Founded in 2006 by civil rights activist Tarana Burke, the MeToo movement
initially sought to provide resources and advocate for survivors of sexual
violence, particularly young women of color from low-wealth communities
(www.metoomvmt.org, 2018). The hashtag (#MeToo) went viral on social
media in October 2017, after film producer Harvey Weinstein was accused
of sexual violence by over eighty women in the entertainment industry
(Moniuszko and Kelly, 2017). The movement has since prompted women
(and some men) in a wide range of industries to publicly expose instances
of sexual violence. These include abuses that have taken place in politics
(Godfrey et al., 2018), sports (Reel and Crouch, 2019; Zeegers, 2019), reli-
gious institutions (Griswold, 2018), education (Anderson, 2018), medicine
(Smith, 2018), and the military (Cohen, 2018). While the movement started
in the United States, it has also had a global reach. Some of the countries
that have had their own #MeToo conversations include Pakistan, South
Korea, Sweden, Egypt, Japan, Israel, and France (Adam and Booth, 2018;
Stone and Vogelstein, 2019).
While it is too early to tell what the long-term impact of the #MeToo move-
ment will be, many analysts speak of it as a catalyst for a cultural shift (Be-
itsch, 2018; Fileborn and Loney-Howes, 2019; MacKinnon, 2019). Since the
movement went viral, it has met with some backlash (Bower, 2019; Kottasová,
2019), but has nonetheless persisted as a powerful influence and support for
people exposing and prosecuting sexual violence. Organizations that work to
prevent sexual violence and assist victims have existed long before #MeToo,
and have presented a range of interventions that may help to decrease rates of
sexual violence. Some of these include:
• To promote social norms that protect against violence (e.g., bystander ap-
proaches, mobilizing men and boys as allies).
• To teach skills to prevent sexual violence (e.g., teaching healthy, safe
dating and intimate relationship skills to teens; promoting healthy
sexuality).
• To provide opportunities to empower and support girls and women
(strengthening economic supports for women and families, strengthening
leadership and opportunities for girls).
• To create protective environments (improving safety and monitoring in
schools, establishing and consistently applying workplace policies).
• To support victims/survivors to lessen harms (victim-centered services,
treatment for at-risk children and families to prevent problem behavior
including sex offending) (“Preventing Sexual Violence,” 2020, Centers for
Disease Control and Prevention, CDC).
This is not an exclusive list of tools for preventing sexual violence, but it high-
lights that prevention strategies need to address both broader socio-cultural
dynamics and local structural implementation. Such strategies also need to
assume an intersectional approach and take the needs of the most highly vic-
timized groups (e.g., people of color, LGBTQ communities, people who are
economically disadvantaged, seniors, and people with disabilities) into ac-
count. With increased awareness about sexual violence and its prevalence,
and with greater allocation of resources for prevention and victim support, the
rate of sexual violence may decrease further.
In conclusion, this chapter has presented terms and concepts necessary for
understanding human sexuality from an anthropological perspective. We have
elaborated on the importance of culture in shaping our human sexuality, and
have offered an examination of key concepts and points related to biological
and psychological dimensions of sexuality.
Summary
1 Psychology, sociology, and biology offer useful perspectives for the under-
standing of human sexuality. These viewpoints are incorporated to vari-
ous degrees by anthropological approaches.
2 To understand the bio-cultural perspective, it is necessary to define our
terms. These include concepts and constructs such as evolution, the cul-
ture concept, ethnocentrism, and cultural relativism.
3 Definitions of human sexuality have varied temporally and spatially.
4 Definitions of human sexuality include areas such as anatomy and physi-
ology, the sexual life cycle, and human sexual response.
5 Sex has many components. These include behavioral, cognitive, affective,
and symbolic dimensions.
6 Sex and gender are compared and contrasted.
7 Sex has been used to serve larger cultural ends in societies. We examine
sex in the context of power and politics.
8 Sexual violence is found across many different cultural contexts and re-
mains a complex human social problem.
1 What is the relationship of the individual to culture and psychology?
Provide an example of how sexuality represents this intersection.
2 How has the information in this chapter challenged you to think differently
about your beliefs about what is “naturally” feminine or masculine?
3 Think of a specific behavior related to sexuality (e.g., sexual dysfunctions, at-
titudes about sexuality, the use of safer sex techniques) and identify potential
behavioral, cognitive, and affective factors that might influence the behavior.
4 What have you learned in this chapter that you would choose to share
with a partner or friend? Why did you choose this piece of information?
How do you think it will influence your own thoughts and behaviors or
those of the person you are sharing the information with?
Suggested Resources
Books
Altman, Dennis. 2002. Global Sex. Chicago, IL: University of Chicago Press.
Lancaster, Roger N. 2003. The Trouble with Nature: Sex in Science and Popular Culture.
Berkeley: University of California Press.
Lyons, Andrew P., and Harriet Lyons. 2004. Irregular Connections: A History of Anthro-
pology and Sexuality. Lincoln: University of Nebraska Press.
Websites
Alan Guttmacher Institute. www.guttmacher.org.
Association for Feminist Anthropology. http://sscl.berkeley.edu/~afaweb/index.html.
Gender Inn. http://www.uni-koeln.de/phil-fak/englisch/datenbank/e_index.htm.
Kinsey Institute for Research in Sex, Gender and Reproduction. www.indiana.
edu/~kinsey.
National Sexual Assault Telephone Hotline (available 24/7) 1–800–656–HOPE
(4673). Online live chat is also available. www.rainn.org.
National Domestic Violence Hotline (available 24/7) 1–800–799–SAFE (7233) or
1–800–787–3224 (TTY).
Online live chat is also available.www.thehotline.org National Sexual Violence Re-
source Center 1–877–739–3895. www.nsvrc.org.
3 The Evolutionary History of
Human Sexuality
Wenda R. Trevathan
Chapter Overview
1 Presents an overview of non-human primate evolution and ancestral
relations.
2 Discusses the consequences of human arboreal and terrestrial adaptations.
3 Focuses on the development of the grasping hand, stereoscopic vision,
and grooming.
4 Considers the consequences of these adaptations for modern sexual be-
havior including the importance of touch, feeling, and vision as import-
ant components in sexual attraction.
5 Presents discussion of the importance of bipedalism, loss of estrus, the de-
velopment of brain complexity, infant dependency, and reliance on learn-
ing and examines the profound consequences this has had on hominid
evolution and human sexuality as well as reproduction.
6 Explains the importance of the social group for human survival.
7 Introduces the concept of bonding in human and non-human primates.
8 Relates how the human brain is actively involved in human maturation,
reproduction, and sexuality.
9 Addresses estrus and loss of estrus and its implications for human
evolution.
10 Offers discussion of several controversial views on the role of orgasm for
female evolution.
This book focuses on human behavior as it relates to sexuality. Human be-

havior is notably complex and requires us to look for explanations for certain
behaviors at multiple levels. For example, if we want to understand why a per-
son acts aggressively in a given circumstance, we must investigate the immedi-
ate environment and events that might have triggered an aggressive reaction.
What in this individual’s life history could help explain the reaction? What
aspects of his or her cultural environment and socialization might explain the
behavior? Let’s say we are observing a nursery school classroom. We watch as
a little girl approaches a little boy and tries to take a toy from him. He hits
her. Why did he behave this way? Multiple explanations can be offered. He
was provoked by her. Boys are socialized in this culture to act with aggression
48 The Evolution of Human Sexuality
when their property is threatened. Or perhaps one could take an evolutionary
view and argue that males have been selected to act aggressively and posses-
sively under certain circumstances because those behaviors were adaptive in
the past.
These multiple explanations can be roughly placed into three categories,
or “levels of explanation.” One, the proximate level, seeks causes in the
immediate environment, both the external and internal environment. In
the case here, the provocation by the girl can be seen as the most direct
cause, the proximate cause. Physiological changes that the boy might have
experienced as a result of the provocation (e.g., anxiety) may also be seen
as proximate causes. The ontogenetic or developmental level seeks causes
in external and internal experiences in the individual’s lifetime. Learning,
socialization, previous related experiences, all would be in this category.
Finally, the evolutionary explanation can be considered the ultimate level
of explanation. When a behavior is seen as being the result of natural
selection, as having “adaptive significance,” then it can be seen as the ul-
timate cause.
These levels of explanation are not mutually exclusive. No single level is
necessarily more correct than the others. It is true that hypotheses about prox-
imate causes can more easily be tested. For example, if a loud noise had imme-
diately preceded the aggressive reaction of the nursery schoolboy, an observer
might be unsure of which event, the noise or the threatening action of the girl,
had provoked the reaction in the boy. This could be tested experimentally by
having the loud noise occur without the provocation from the girl, and vice
versa. Ontogenetic or developmental hypotheses can be indirectly tested by
observing similar situations involving other members of the boy’s family, other
boys in the nursery school environment, boys in different social groups, and
boys in different cultures. Evolutionary explanations are far more difficult, if
not impossible, to test, and for this reason may be less satisfying. Those with
an interest in the physiological basis of behavior will find more satisfaction
in proximate levels of explanation. Those with an evolutionary interest will
focus on ultimate causes. Again, this does not mean that one explanation is
any better than another, but one may be more meaningful to an investigator
than another.
Let’s try some more examples. Why do male birds sing in the spring? Hor-
mones (proximate); photoperiod (proximate); learning by observing other
males (ontogenetic); to mark territory (ultimate); to attract a mate (ultimate).
All of these answers are correct, on one level or another. Why does a male
dog mount a female dog? She’s in heat (proximate); to reproduce (ultimate).
These examples help us see another way of looking at these multiple levels of
explanation. The proximate can be considered the “cause” of the behavior,
while the ultimate can be considered the “function” of the behavior. Here’s
another: Why do men and women differ in their sexual behaviors? Chro-
mosome differences (proximate); differences in brain structure (proximate);
The Evolution of Human Sexuality 49
different hormones (proximate); socialization (ontogenetic); natural selection
(ultimate). No one explanation is more correct than another; they are com-
plementary rather than exclusive. In this chapter we will emphasize the evo-
lutionary explanations, whereas other chapters focus more on ontogenetic and
proximate factors that help us understand human sexual behavior.
To begin our discussion of the evolutionary history of human sexual
behavior, we need to have a basic understanding of evolution. As noted
previously, in most cases, evolutionary success is measured in terms of repro-
ductive success. In other words, biological, behavioral, and physical features
that enhance reproduction will usually be favored by natural selection over
those that do not contribute to greater reproductive success. The “winners”
in the evolutionary race are those that have the most surviving offspring,
not just those who live long and healthy lives. Thinking of evolutionary
success in this way enables us to reconsider many of the “why” questions that
arise when we think about aspects of human sexuality. Examples include,
why do human females have sex even when they are not likely to conceive,
whereas other female primates have sex primarily or exclusively when they
are ovulating? Or why do most humans remain in long-enduring pair bonds,
whereas males and females in most mammalian species come together briefly
for mating and then live most of their lives separately? Why are human in-
fants so helpless at birth in comparison to many other mammals, including
most primates? We will see that at one level, the answer to each one of these
questions is because this behavior or characteristic increased reproductive
success in the past.
One of the ways in which we can try to understand how human sexuality
evolved is to study our closest living relatives, the non-human primates (see
Figure 3.1 for the taxonomy that has been developed to show how humans are
related to other animal species). Examining the similarities and differences
in biology and behavior related to sexuality can help us understand how they
might have evolved through time and space. When we consider evolution-
ary changes, we understand that certain characteristics have adapted to spe-
cific environmental contingencies and, because they enhanced reproductive
Kingdom Animalia
Phytum Chordata
Subphylum Vertebrata
Infra class Eutheria
Order Primates
Suborder Anthropoidea/Haplorhini (dry nose)
Super family Hominidae
Genus Homo
Species Erectus (archaic)/sapiens (present day)
Figure 3.1 The place of humans in the biological taxonomy of living organisms.
Source: Jurmain, Kilgore, and Trevathan, 2005: 109, 150.
Some traits are

These traits The frequency of
ADVANTAGEOUS
are selected these traits in the
in the new
FOR species
environment (e.g.,
INCREASES
grasping hand)
Environmental
change (e.g.,
increase in
forested areas)
Some traits are

The frequency of
DISADVANTAGEOUS These traits
these traits in the
in the new environment are selected
species
(e.g., non-grasping AGAINST
DECREASES
hands)
Figure 3.2 How natural selection works on traits.

Source: Trevathan, 2006.
success, they survived in subsequent generations (see Figure 3.2). In this chap-
ter, we are going to discuss aspects of our primate heritage that some research-
ers believe serve as models for early hominid1 sexuality and that affect our
modern human sexual behavior.
Non-human primate models are valuable in several ways. They help to show
the continuities with other species of our order, and illustrate the high intelli-
gence and sociability of primates. The models can serve as a reality marker to
check our own biases and perspectives regarding dominance, division of labor,
and sexuality. They provide evidence of the relationship of ecological variables
such as food, shelter, and predators to social behavior and indicate the variety
and flexibility of primate behavior and patterns of intra- and intergender and
group cooperation and competition that may be evolutionarily deep-seated.
Primate analogies may serve as models for reconstructing early hominid be-
havior. We need to be careful, however, not to take these analogies with our
close primate relatives too far or they will defeat the purpose. We must re-
member that we have had our own line of evolution for 5–8 million years and
have adapted to almost every econiche on the planet. The development of
our cerebral cortex allows for qualitatively different kinds of communications
and social relations than other primates. These variables have worked to our
advantage and disadvantage relative to the expression of our sexuality. Our
complete dependence on language, sophisticated social systems, and complex
technology make us very different animals from any others that live or have
lived on our planet.
Because of their close immunological, genetic, and behavioral similarities
to humans, the common chimpanzee (Pan troglodytes) and pygmy chimpan-
zee or bonobo (Pan paniscus) are frequently used as the most appropriate pri-
mate models for reconstructing the human past. We will follow that common
practice by examining ways in which chimpanzee and human sexuality differ
and are similar, and we will posit the evolutionary significance of the differ-
ences. But we need to start at the beginning. The fundamental aspects of
our evolutionary history that affect our sexuality can be discussed under four
topics:
1 adaptations first to arboreal and then to terrestrial environments, leading

in humans to bipedalism;
2 increasing brain complexity, leading in humans to dependence on lan-
guage, learning, and culture;
3 social organization, leading in humans to male-female pair bonds, sexual
division of labor, and long infant and child dependence on family support;
and
4 sexual receptivity in females, leading in humans to the “loss of estrus” and
sexuality unrelated to reproduction.
Arboreal and Terrestrial Adaptations

By the Eocene (54–38 million years ago), evidence of our first primate an-
cestors, the prosimians (sometimes referred to as strepsir-rhines), appeared.
Profound changes were brought about by adapting to “life in the trees,” also
known as an arboreal niche. As a result of the arboreal adaptation, primates
developed certain shared physical and behavioral features, primary among
them the grasping hand, sensitive fingers and toes, as well as stereoscopic
vision.2 Hominid terrestrial adaptation is believed to have occurred around
8–5 million years ago. This movement from the trees to the ground was af-
fected in part by climatic changes as forests in Africa gave way to savan-
nahs setting the scene for the development of bipedalism (walking on two
legs). This freed the hands for carrying objects and manipulating them. It
facilitated the primate trajectory of enhanced brain complexity, infant de-
pendency, and reliance on learning, discussed later. It was not until about 2
million years ago that the brain enlarged significantly with the appearance of
Homo erectus, an early human remarkably like modern people in appearance
from the neck down.
The Grasping Hand, Sensitive Touching, and Grooming

Primates have five digits on their hands and feet and most species are able to
oppose the thumb and big toe to the other digits, enhancing the ability to
grasp objects, including tree branches. When primate ancestors moved into
an arboreal niche, the ability to grasp had obvious advantages so this trait was
likely favorably selected and descendants of those early primates have grasping
hands and feet (human feet are exceptions to this and reflect subsequent adap-
tation to bipedalism). Likewise, having sensitive pads on the fingers and toes
was advantageous for moving in the trees and locating insects and ripe fruit,
so today, touch is a very important sense for all primates. For humans the sense
of touch is extremely important. In the course of hominid evolution, the loss of
body hair probably enhanced touch as a means of assessing one’s surroundings
including the social milieu. It is linked with the unique development of pri-
mate forelimbs including the hands, precision gripping, tactile sensitivity, and
manual motor skills.
Harlow and his colleagues demonstrated long ago that touch is more im-
portant to infant monkeys than food. Monkey infants who are deprived of
touch do not develop normally physically or socially (Harlow, Harlow, and
Hansen, 1963). Social touch, referred to as “grooming,” is a distinguishing
characteristic of primates that serves a number of functions including mainte-
nance of social cohesion (Seyfarth, 1983); reduction of stress (de Waal, 1989;
Goodall, 1986; Taylor et al., 2000); and hygiene. Given that our closest living
relatives (monkeys and apes) spend 10–20 percent of the day involved in so-
cial grooming (Dunbar, 1996) and that human skin has a significant number
of sensory receptors and nerve fibers (Greenspan and Bolanowski, 1996), we
can infer that engaging in rewarding social touch was characteristic of human
ancestors, and likely played an important role in sexual interaction. In human
sexual activity, grooming is symbolically translated into stroking and patting
and may also be found in a variety of cultural activities including cleansing
of parasites; combing and arranging hair; and adorning one another’s bodies
with paints, feathers, and/or clothing. All of these involve the sensations of
touch and sociality. Ford and Beach’s (1951) Patterns of Sexual Behavior, a clas-
sic survey of the ethnographic literature on traditional peoples, reports that
human grooming activities are frequently precursors to sexual relations and
may be an integral part of foreplay in contemporary human cultures in which
sex is treated in a positive manner. Whereas tactile contact between mother
and infant and between sexual partners seems to be universally distributed
in human cultures, other forms of social contact vary by gender, social class,
and culture (Hall, 1966; Hall and Hall, 1990; McDaniel and Andersen, 1998;
Montagu, 1978; Remland et al., 1995). In fact, touch between non-intimates
or non-family members is often strictly regulated by cultural norms (see, for
example, Hickson, Stacks, and Moore, 2004).
While we have the primate propensity for touch; rules, attitudes, and
behaviors about touching and body space are culture-specific. For exam-
ple, our culture has been described by some sexologists and sex therapists
such as Domeena Renshaw, MD, as “touch deprived” (Renshaw, 1976).
We have rather rigid rules about touching and body space and tend to
confuse affection with sexual touching. Most dramatically, this can be
illustrated by a middle-class value on newborns, infants, and children
“having their own room” and sleeping separately from their parents and
siblings from birth. In contrast, in many traditional societies, women
carry their infants with them while engaging in their daily activities and
parents and children share a common sleeping space.
Vision and Olfaction
In addition to the development of the grasping hand, our primate ancestors
acquired highly developed visual cortices from their arboreal adaptation that
remain with us today. Primate eyes are large, binocular, and stereoscopic and
allow diurnal and color vision (Jurmain, Kilgore, and Trevathan, 2005). This
represents a shift to vision from reliance on smell as a vehicle for information
processing. Although smell (or olfaction) may still be important in sexual in-
teraction (Pawlowski, 1999; Stoddard, 1990), visual cues provide much initial
information about potential sexual partners for humans. Females in several
primate species, including chimpanzees, have clear visual signals that they are
in estrus (to be discussed later), that is, they are receptive to sexual advances
from males. Their genital areas exhibit brightly hued purple swellings at the
time of maximum likelihood of ovulation and this is when males are most
interested in copulating with them.
Evolution of Bipedalism
There is much debate among scholars of human evolution (known as paleo-
anthropologists) about the reasons that bipedalism evolved in our species,
but, like most other evolutionary changes, there is little doubt that it was
related to climate change. About 7 million years ago, a drying trend in
Africa resulted in a decrease in forested areas and an increase in woodlands
and savannahs. At some point, human ancestors began spending more time
in the savannahs and less time in the forests, although, like other terrestrial
primates, they probably returned to the trees at night to sleep more safely.
It was formerly hypothesized that movement into the savannahs preceded
evolution of bipedalism, but recent evidence suggests that our ancestors be-
came bipedal before they moved into the savannahs (Jurmain, Kilgore, and
Trevathan, 2005). It is beyond the scope of this book to resolve the question
of why humans became bipedal, but some hypotheses conclude that selec-
tion favored this form of locomotion because it enhanced the ability to see
over tall grass, gather food, lower the costs of movement through greater
energy efficiency, avoid predators, free the hands for carrying objects and
babies, and for males to provision females and infants (Jurmain, Kilgore,
and Trevathan, 2005). Suffice it to say that all of these behaviors are com-
mon in humans today because we are bipedal, and this mode of locomotion
is the hallmark of our species in the fossil record. In other words, if the fossil
primate is bipedal, it is, by definition, hominid (Jurmain, Kilgore, and Trev-
athan, 2005). As we shall see, the subsequent evolution of the human brain
is intimately linked with bipedalism, embellishing characteristics already
developed in ancestral primates such as a large ratio of brain to body size.
Bipedalism had a consequence for the evolution of the hand and manipu-
lation of tools, the elaboration of the motor areas of the brain, as well as
memory and thinking.
Bipedalism also had a profound impact on the evolution of human sexuality
and reproduction. A number of skeletal and muscular changes accompanied
upright posture. One of the major changes in anatomy that had an impact on
hominid sexuality included a tilting forward of the pelvis; it became shortened
and flared as well. The genitalia were moved forward and the female genitals
became less exposed and more hidden than those of the male. Although we
don’t know if our human ancestors exhibited bright genital swelling when they
were in estrus, these sexual swellings would have been difficult to see during
bipedal walking and standing, so other ways of communicating sexual recep-
tivity were developed. These were probably related to the expansion of com-
munication skills in general, an essential component of culture.
With the shifting forward of the hominid female genitalia, face-to-face sex
was a possibility and perhaps a probability. We are not necessarily referring
here to the “missionary position” where males are on top, since this is not even
the most preferred position cross-culturally. Face-to-face sex includes positions
in which the female is on top of the male or side by side. The position of the fe-
male genitalia in a more forward location certainly contributed to the human
potential for a wide array of sexual positions.
Changes in the pelvis also affected childbirth by placing upper limits on
the size of the birth canal (Trevathan, 1987). These limits, associated with
increase in adult brain size in the last 2 million years of human evolution,
have meant that the human infant is much less developed at birth than our
closest primate relatives. In order for a species with such large heads to be
born through a rather narrow birth passage, natural selection favored birth at
an earlier stage of development before the brain had reached the size of most
primate newborns. This meant that the human newborn was more helpless at
birth and required much greater care from the parents, especially the mother.
This also meant a longer period in which the infant was dependent on paren-
tal care, a period that became very important for learning.
Evolution of the Brain

About 2 million years ago, the fossil record of humans shows evidence of in-
creasing brain size. This is not to say that size alone indicates intelligence. We
may assume that the small brains of the earliest hominids were also relatively
complex ones. After all, chimpanzees are very intelligent creatures. The adap-
tive strategies utilized by the earliest hominids may have promoted a certain
amount of cognitive complexity prior to the actual physical expansion of the
brain. Generally, however, hominid trends indicate a correlation between in-
creases in the size of the brain and complexity.
The early foraging strategies associated with an omnivorous diet (if it was
smaller or less powerful than they were, they probably ate it) expedited the
expansion of the brain complexity. In seeking food and carrying it someplace,
the human capacity for evaluating circumstances and making decisions grew.
To take something from one place to another requires brain power and the
capacity for displacement—thinking about something that is not present in
one’s immediate environment. To make tools and baskets requires the articu-
lation of cerebral centers with motor skills. The cognitive task of remembering
locations of sites and sources for food, some of which were seasonal, also re-
quired a high level of cerebral functioning.
Throughout the course of hominid evolution, we can assume that humans
continued a pattern of dependence on learning and hence culture as a pri-
mary means of survival. The size and complexity of the human brain reflect
the increased reliance on learning as a means of adaptation. We adapt to our
environment primarily through culture. Remember, culture is learned, shared,
patterned behavior, including symbols and beliefs that are expressed between
and within generations, individuals, and groups. We need to interact with oth-
ers of our own kind regularly in order to survive and be functional members
of society. Like most primates, humans are known for their flexible behavioral
patterns.
The development of a large and complex brain with elaborate centers that
include memory, language, and symbolizing, to name just a few, is directly re-
lated to our sexuality. Human sexuality is experienced and mediated through
a complex web of cerebral functioning that includes the capacity for elaborate
fantasy, dreams, verbal and non-verbal thinking and images. Our human her-
itage as social beings facilitates how we communicate our sexuality, which is
experienced as much in our “heads” as it is in our genitals. In addition, because
we rely on learning for just about everything we do, sexual behavior, like other
parts of our culture, is also learned. During our early lives, we learn how to
experience our sexuality, including appropriate courtship behaviors, gender
roles, and related norms and values. The biological capacity for sex is therefore
intricately intertwined with a matrix of cultural constructions that shape our
perceptions, experiences, and expressions of human sexuality.
Evolution of the Human Family

As primates became bipedal, hands and arms could be used for carrying. With
freed hands, early hominids could carry their babies and other objects. Based
on contemporary gatherers and hunters, hominids probably used a strategy of
carrying food back to some sort of base camp rather than just eating it on the
spot, as most other primates do. Perhaps the females shared the food they col-
lected with their infants and young children first and then with other kin and
friendly unrelated males. The earliest stone tools appeared in association with
evidence for an expanding brain. These were probably predated by tools and
implements made of organic material that related to a food-gathering strategy.
Digging sticks and some sort of basket or net for carrying food items and babies
could have been included. Unfortunately, we have no remains of these tools
because they were made of organic materials that decompose rapidly.
Although most scenarios of human evolution put hunting by males as a
central component, we posit that both males and females gathered plants and
animal protein and used their expanding brains to hunt or chase small prey.
Communal and group hunting by the Mbuti of the Ituri forest is well docu-
mented. There is ample evidence of women hunting small animals (Ehren-
berg, 2005; Mascia-Lees and Black, 2000; O’Kelly and Carney, 1986: 12–21).
Among the Agta of the Philippines, women hunt larger game including wild
pigs and deer and participate in spear fishing as well (Estioko-Griffin, 1993:
225–232; Estioko-Griffin and Griffin, 2005: 141–150; Headland and Griffin,
2005). It is not necessary to propose that only men hunted unless the prey was
some variety of large game.
But if we survey all known world cultures, we find that at least with large
game hunting, the most common pattern is for men to be the hunters, even
though women engage in smaller game or communal hunts.3 Thus, we have
a “why” question: Why is big game hunted primarily by men? The answer is
related to the dangers inherent in hunting large animals and the impact of
those dangers on reproductive success. Hunters can be wounded or killed
in the hunt by either wayward spears in motion or the charges of a wounded
animal. Also, big game hunting can involve exploring new frontiers—whose
dangers, human or non-human, are unknown. Females who engaged in these
relatively dangerous activities risked not only their own lives, but the lives of
their fetuses, nursing infants, and dependent children. A related idea is that
males are more expendable (it takes only one to contribute sperm) and there-
fore can “afford” to engage in more high-risk behaviors (Mukhopadhyay and
Higgins, 1988). The costs of big game hunting to female reproductive success
were usually greater than the potential benefits, whereas males, it is argued,
stood to gain access to sexually receptive females via successful hunts and
they were able to provide their mates and offspring with high-quality animal
protein. In most cases, the benefits of large game hunting to male reproductive
success outweighed the costs.
Furthermore, both males and females have finite amounts of energy to ex-
pend and the costs of reproduction are much greater for females than for males
(e.g., the costs of pregnancy and lactation are much higher than the costs of
producing sperm). Thus, a female who puts her energy and efforts into bearing
and raising healthy offspring will usually have more surviving offspring and,
thus, greater reproductive success than one who puts her energy into hunting
big game. An excellent example of this division of labor is seen in reports of
hunting behaviors of the chimpanzees of the Gombe National Park in Tanzania
(the community in which Jane Goodall conducted her famous studies). From
1982 to 1991, primatologists reported 195 kills of red colobus monkeys by 17
members of the community (Stanford et al., 1994). Fifteen of the hunters were
males and two were females, and, in fact, a female named Gigi was ranked
ninth in the number of kills, ahead of seven and equal to one of the males.
Doesn’t this suggest that hunting by females may have been common in our
ancestors? Perhaps, but the most interesting thing about Gigi is that she was
apparently sterile and never had dependent young to care for. Thus, she was
freed to engage in the relatively risky and energetically expensive endeavor of
hunting without compromising her reproductive success any further than it
was compromised already by her sterility. This suggests that females are men-
tally and physically quite capable of large animal hunting, but they rarely en-
gage in the activity because of possible risks to their offspring. We would argue
that similar conditions prevailed in our ancestors.
If ancestral women hunted small game and gathered other food resources,
does this mean that they were much less dependent on men than men were
on women for reproductive success in the past, and perhaps today, as well?
Certainly males probably contributed by protecting the group; but is there any
reason to believe that pair bonding beyond the period of sexual receptivity of
the female was common in our ancestors? To explore this, we need to consider
the helpless human infant that resulted from bipedalism and brain expan-
sion. After impregnating a female, a male can either leave for another mating
opportunity or can remain with the newly pregnant female and assist her in
pregnancy and in raising the infant after it is born. If the male doesn’t assist
his mate in raising their children, her ability to have more than one depen-
dent offspring at a time is severely constrained. If, however, the male stays and
serves as caretaker for older children, she may be able to give birth every two
to three rather than every four to five years, effectively doubling the number
of children the pair can produce and successfully raise. Furthermore, if the
male also provides some food resources to his family, in addition to those pro-
vided by the female, the entire family is more likely to survive, reproduce, and
remain healthy. Infant mortality was probably much higher for the offspring
of males who followed the “love ‘em and leave ‘em” strategy than for those
who were provided paternal care. These are sometimes referred to as the “cad
strategy” and the “dad strategy” (Cashdan, 1993), and the latter is believed to
be related to higher reproductive success in ancestral and some contemporary
human populations.
In some cases, having more than one “father” may be advantageous, how-
ever. A common response of female chimpanzees and langurs to infanticidal
males is to “confuse paternity” by mating with several males during estrus
(Hrdy, 1999). In some human cultures, this has been referred to as shared or
“partible” paternity (Beckerman and Valentine, 2002), wherein more than one
male assists in caring for children, particularly if it is possible that any of them
could be the genetic father. In a few South American cultures where this con-
cept exists (e.g., the Canela of Brazil), there is a belief that all men who have
intercourse with a woman at the time she gets pregnant contribute to the
makeup of the fetus. Ethnographic research among the Ache confirms that
children with multiple fathers who provide them with care and resources are
more likely to survive than children with single fathers; the optimum number
of fathers appears to be two (Hurtado and Hill, 1996). As Helen Fisher (1992)
has noted, adultery has probably always been an important reproductive strat-
egy for women.
But do women in modern technologically advanced societies still need men
to help with raising children? Despite recent reproductive technology, men still
need women to impregnate, carry the fetus, give birth, and in many societies,
breastfeed, to ensure the survival of the child. Now that we have technology to
create babies, such as in vitro fertilization; chromosome selection; sperm banks
and artificial insemination; technology for infant feeding, such as bottles and
infant formula; and technology to secure our food and fight wars, there may
well be a shift away from the need for women to act as primary child caretakers
and from the two-parent family. How successful these new child-rearing strat-
egies will be remains to be seen.
The development of lifelong social relationships or attachments is a hom-
inid characteristic that reflects continuities from our non-human primate
heritage (Hrdy, 1981, 1999; Jolly, 1985). We will review and illustrate the ma-
jor forms of primate bonds or attachments as they relate to human sexuality.
As stated, adult female–child bonds are probably one of the oldest, deepest,
and most primal forms known. Female–child bonds are supported by female–
female bonds which can be either cooperative or competitive. Cooperative
female–female bonds are generally kin-based or take on kin terminology if
not of biological (consanguineal) or marital (affinal) relations. These non-
kin relations are called fictive kin and can be exemplified by relationships
such as sorority “sisters” or by phrases such as “she is like a sister to me.” Co-
operative female–female bonds provide psycho-emotional support (Taylor
et al., 2000), and socialize females into “female” behavior. Competitive female–
female bonds in both the human and non-human primate worlds generally are
adversarial over males. In humans this can be expressed by jealousy among
co-wives in polygynous societies where men have more than one wife; or cur-
rent US culture wherein one female pursues another female’s man (i.e., the
“other” woman) (Brown and Kerns, 1985; Fernea, 1965; Kilbride, 2005; Ward
and Edelstein, 2006: 54–55).
Female–male bonds may also be cooperative or competitive. Cooperative
female–male bonds tend to be non-sexual and take on familial characteristics—
siblings or fictive sibling relations—“He is like a brother to me.” They can
provide a great deal of socio-emotional support, protection, and friendship. In
matrilineal societies where descent is through the female line and a woman’s
brother often fills the social role of “father” to his sister’s children, brothers and
sisters have a lifelong supportive relationship that can supersede their marital
relationships (Robbins, 2006: 172–173, and the classic work of Kluckhohn and
Leighton, 1962). Competitive male–female bonds often are sexual and revolve
around issues of trust, intimacy, and sexual exclusivity. Concern over adult
male–female relations is culturally widespread. In much of the world, adult
male–female contacts outside the kin group are carefully circumscribed due
to the belief that leaving unsupervised adult men and women together would
“naturally” lead to sex (Faust, 1988; Fernea, 1965; Kilmartin, 2000: 269–270;
Mernissi, 1975; Schlegel, 1977; Whelehan’s field notes).
A whole “cottage industry” has developed around exploring factors that
affect male–female mate choice in humans. Based on predictions derived
from evolutionary theory, one idea is that men tend to be attracted to more
youthful and attractive women because younger women have a greater number
of years ahead of them to reproduce, whereas women tend to be attracted to
men with more resources (who often, but not always, tend to be older) who
can share those resources with her (their) children. Evolutionary psychologists
have examined concepts of beauty to reveal that in many cases, the most at-
tractive face or body shape is the most symmetrical (Singh, 1993; Thornhill
and Gangestad, 1994). It appears that symmetry is related to health, meaning
that the more symmetrical face or body is healthier and likely has the “best
genes” (Hamilton and Zuk, 1982). In support of these predictions, David Buss
(1989), who surveyed more than 10,000 people in thirty-three different coun-
tries, found that, consistently, women rated “good financial prospect” as more
important in a mate than men did and that men rated “good looking” higher
than women did. Of course, all we have to do is look around us and we will see
many examples of mate choices that deviate from these predictions. Certainly,
there is great individual variation in what each of us finds attractive in our
mates, but when we survey thousands of people, as evolutionary psychologists
tend to do, we find that the predictions hold up more often than not.
Adult male–child bonds generally occur between males and those children
the men believe to be their offspring. In patrilineal societies where descent
passes through the male, and bilineal or bilateral descent societies where de-
scent passes through both males and females, but paternity is necessary for a
child’s place in the kinship system, knowing the biological father of the child
is important. This knowledge is culturally secured by creating sexual double
standards for males and females and placing female sexual behavior under re-
striction to ensure paternity (i.e., known fatherhood). Examples range from
calling a female, in US society, who has a number of sexual partners a “slut” or
“whore” to “madonna-whore;” the latter occurring in many agricultural societ-
ies where a woman is seen as virtuous as a sister and mother (i.e., non-sexual)
and a whore as a wife where her sexuality is expected and obvious, as well as
“machismo/marianisma” complexes of Latino cultures that emphasize male sex-
ual prowess and female faithfulness among other characteristics.
Analogous to female–female bonds, male–male bonds can be both com-
petitive and cooperative. Competitive male–male bonds in the human and
non-human primate worlds center on dominance—status, power, position in
a hierarchy—and sexual access to females. This is exemplified in human cul-
tures by ongoing warfare found in horticultural societies (a form of farming
discussed in Chapter 10). In these societies all resources—land, water, food,
women—are in scarce supply. Ongoing warfare serves to forge political alli-
ances and is a source of women. Wives are found among the warring factions
and foster alliances between different groups. In US society, male–male com-
petition can be found in amateur and professional sports as well as for positions
in the labor force. Competition for women is well known. In US culture, males
use their power, status, and economic success to attract women (Farrell, 1974,
1986; Goldberg, 1976, 1979, 1980; Kilmartin, 2000; Zilbergeld, 1978, 1992).
Cooperative male bonds, exemplified by fraternities, men’s groups, and men’s
houses in horticultural societies provide a sense of male solidarity and support,
often to the exclusion and derogation of females (Buckley and Gottlieb, 1988;
Murphy and Murphy, 1974; Robbins, 2006; Sanday, 1990).
Evolution of Intimacy
The concepts of psychological masculinity and femininity have been widely
discussed in the United States since the 1970s by writers such as Hite (1976,
1981, 1987), Cassell (1984), Farrell (1974, 1986, 1993), Zilbergeld (1978, 1992,
1999), Goldberg (1976, 1980, 1984), and Tanner (1995, 2001). Relative to rela-
tionships, this research generally explores what men and women need and want
from each other and in their romantic and love relationships. In essence, this
research states that men and women have very similar needs and wants in rela-
tionships. However, their means of expressing and getting their needs met are
different, and are not necessarily well communicated to or well understood by
the other gender. For example, both men and women state they want emotional
bonding and depth in their relationships and that trust, being able to be one’s
self, and honesty are important. They also state they value these needs over
genital sexuality, per se. However, according to the work by the researchers cited
above, culturally defined ways of communicating and meeting these needs and
perceptions of the other gender may either impede or enhance need fulfillment.
In general, men and women attitudinally and culturally still fulfill their scripts,
those socially defined roles of masculinity and femininity (Gagnon and Parker,
1995; Gagnon and Simon, 1973). People’s deep sense of who and what they are,
regardless of their overt behavior, rests on fairly well-ingrained pre-1960s ideas
of masculinity and femininity. This is expressed in women when they value
relationships, communication, and being physically attractive over sexuality per
se and when they assume primary responsibility for the relationship (Cassell,
1984; Hite, 1976, 1981, 1987; Tanner, 1995). Men express this by using sex as an
example of emotional caring by defining the quality of a relationship sexually
rather than through verbal or affective means, or choosing partners primarily
on physical characteristics (Farrell, 1974, 1986; Fisher, 2004; Goldberg, 1976,
1980; Hite, 1981; Zilbergeld, 1978, 1992).
The result is that while needs for closeness, trust, and bonding exist, the
means people use to express and meet these needs may not achieve this pur-
pose. In addition, pre-1960s rules about male–female interaction have changed.
New ones have not been culturally recognized and accepted socially on a wide
scale. While some individuals have achieved relationship satisfaction, there
is much confusion, anxiety, and miscommunication on a cultural level about
male–female relationships (Tanner, 1995, 2001). There is also a wider variety
of relationships more openly and visibly present in this society today (Blum-
stein and Schwartz, 1983; Lippa, 2006; McWhirter and Mattison, 1984).
One aspect of this phenomenon is the relatively recent focus on inti-
macy. Intimacy, a late-twentieth-century, middle-class term, essentially is a
relabeling of the anthropological concept of bonding, a primate and human
primate behavior. As human primates, we need to interact with others of our
own kind and establish close social and emotional or affective ties with each
other. Development of intimacy or bonding rests on bio-behavorial interac-
tion (Fisher, 2004; Perper, 1985). Intimacy develops in stages that include ver-
bal and non-verbal cueing, kinesics, and interaction (Perper, 1985). Perper, an
anthropologist and biologist, suggests that the most elementary steps toward
intimacy may rest in forms of cueing that are universal. Intimacy draws on
our social evolution as primates in relation to our need for continuous social
interaction and recognition from members of our own kind, species, and group.
Paths to intimacy are culture-specific and culturally defined. For example, in
many nonindustrialized societies, adult social intimacy is found with members
of one’s own gender through men’s and women’s groups, initiation ceremonies,
voluntary associations, or extended kin-group participation (Frayser, 1985; Gre-
gersen, 1983; Murphy and Murphy, 1974; Turnbull, 1961, 1972; Ward, 2006).
In the United States, intimacy is an elusive goal. There are a variety of
books, talk shows, and self-help groups to help us achieve intimacy (e.g.,
Goldberg, 1976, 1980, 1984; Hite, 1987). Both men and women in this culture
express a strong desire for intimacy in their social relationships and interac-
tions with one another but seem to have a difficult time achieving it (Farrell,
1986, 1993; Hite, 1987; Kaschak and Tiefer, 2001; Lippa, 2006; McGill, 1987;
Tiefer, 2004). In part, this is due to the changes in socio-sexual rules and
the lack of new, culture-wide rules to guide male-female interaction. Clear,
well-defined roles for male and female behavior and affect no longer exist in
this society. At the same time culture lag exists. Culture lag occurs when
behavior changes faster than the belief systems that support it. There is a lag
or gap between how people behave and the consonant belief system that un-
derlies the behavior. So, people behave one way and may hold beliefs or values
that do not fit comfortably with the behavior. This may be exemplified by
the number of people in counseling for sexual and relationship problems, and
the discrepancy between people’s sexual behavior and the comfort level and
attitudes that accompany one’s behavior (Allgeier and Allgeier, 1991; Kaplan,
1974; Kaschak and Tiefer, 2001; Lieblum and Rosen, 2000; Lieblum and Sachs,
2002; Whelehan and Moynihan, 1984). Intimacy necessitates an acceptance
of interdependency. US values on independence and individuality can work
against intimacy. At this point, we are ambivalent about issues of intimacy
and independence; masculinity/femininity as defined before the “Sexual Rev-
olution” of the 1960s; androgyny, commitment, and autonomy. Concerns with
AIDS and other STDs that impact on fertility and the quality of life intensify
this ambivalence and confusion.
Female Sexuality
Anthropologists are often interested in finding characteristics that are unique
for humans or at least clearly differentiate humans from other animals. Ha-
bitual bipedalism is a characteristic that is commonly cited as distinguishing
humans from all other mammals, as is the dependence on language and cul-
ture. Additionally, aspects of sexuality, particularly female sexuality, are of-
ten presented as “uniquenesses” for humans. These include non-reproductive
and nonovulatory sexual activity (sometimes referred to as “loss of estrus”),
concealed ovulation, the common occurrence of orgasm in women, and, as
previously discussed, pair bonding and paternal care. There is much debate
about whether or not these characteristics are truly unique, but we can at least
say that most are more common in humans than in any other primate species.
We begin with a discussion of the fact that human females engage in a
great deal of sexual behavior that is unrelated to reproduction. As noted, most
other mammalian females seek or allow copulation only when they are likely
to conceive (i.e., when they are in estrus). At the time of maximal likelihood
of conception, female mammals exhibit physical signs (e.g., the red swol-
len perineal area of baboons and chimpanzees); chemical signals known as
pheromones; and behaviors indicative of willingness to be inseminated, so it is
clear to potential partners (and probably to themselves) that they are capable
of becoming pregnant. Beach (1976) proposed three terms to describe aspects
of female sexual behavior: receptivity (willingness to be mated); attractivity
(males are interested in mating with them); and proceptivity (actively seeking
a mating opportunity). For most primates, these three behaviors coincide at
the time of ovulation and are rarely exhibited at other times. For humans,
however, receptivity, attractivity, and proceptivity are largely independent of
the ovarian cycle, although there is some evidence that women may be slightly
more attractive to men when they are ovulating (Tarín and Gómez-Piquer,
2002) and female libido (proceptivity) may rise slightly at the time of ovulation
(Burleson et al., 2002). Furthermore, women well past the time in which they
can reproduce (i.e., postmenopause) often show no sign of diminished interest
in sex or diminished attractiveness, and indeed, their interest in sex may rise
in the first few years after menopause when the likelihood of becoming preg-
nant is no longer a risk.
Concealed Ovulation
Related to the loss of estrus is a phenomenon known as “concealed ovulation,”
meaning that most women and their partners are unaware when they ovulate,
unless they are taking extraordinary measures to track their basal body tem-
perature (BBT) or cervical mucus. When we consider how obvious it is when
a female baboon or chimpanzee is in estrus, it is surprising that humans are
so unaware of when they are likely to conceive. Thus, we have another “why”
question to pursue from an evolutionary perspective. Not surprisingly, there
are dozens of ideas for why human females lost estrus and concealed ovulation.
One scenario that has been around for a long time and fit former stereo-
types about gender roles exemplifies exchange theory in which ancestral
males traded meat for sex with females (Fisher, 1983; Symons, 1979). This has
been observed in some chimpanzee groups (Goodall, 1986), but it is usually
associated with females in estrus, that is, those who are sexually receptive to
the males. If females exhibit signs of sexual receptivity and are willing to en-
gage in sexual activity at times other than when they are ovulating, they may
receive more meat from the males. Eventually, according to this “meat for sex”
scenario, sexual receptivity would become “decoupled” from ovulation and es-
trus behavior (sexual receptivity) would be “continuous.” Females and their
offspring would benefit from additional protein by this economic exchange for
sex. But because males would be more likely to provide food for offspring that
they have some confidence are theirs (“paternity certainty”), they would need
to remain in proximity to the female they are provisioning to ensure that they
are not cuckolded. Accordingly, marriage and the family developed from the
situation of exchange (Symons, 1979).
Another scenario proposes that by concealing ovulation, an ancestral fe-
male could solicit sex from several males so that no one, not even the female
herself, could be sure who the father of her offspring was (Hrdy, 1981). As
noted, this confusion over paternity (“paternity uncertainty”) enabled females
to secure resources from a number of males, and, perhaps more importantly,
minimized the likelihood of infanticide inflicted by males on young that they
were certain were not their biological offspring. According to Symons (1979:
141), “By hiding ovulation, females may have minimized their husbands’ abil-
ities to monitor and to sequester them, and maximized their own abilities to
be fertilized by males other than their husbands” (modified from Burley, 1979).
Yet another scenario for concealed ovulation relates it to population in-
crease in the human species. In this view, ovulation was concealed not only
from males, but from the females themselves, so that they were not able to
control their fertility to the same extent that they could if ovulation were
associated with obvious physical signs. Burley (1979) argues that the fear of
childbirth would have led ancestral females to avoid copulation at times they
were most likely to conceive so they would have had fewer offspring in their
lifetimes. Females who were not aware of when they were ovulating could not
exercise this degree of control over their fertility and would have had more
offspring to pass along the characteristic of concealed ovulation so that today,
it is true for all humans. This scenario invites a play on the paraphrase from
the Bible: “Blessed are those who don’t know when they are ovulating for their
daughters shall inherit the earth.”
The Orgasm in Evolutionary Perspective

We would like to turn now specifically to the issue of the evolution of orgasm,
and the significance of orgasm for reproductive success. The traditional the-
oretical stance is that it is not necessary for women to have an orgasm to be-
come pregnant, but for males the contractions that expel the ejaculate into the
vagina are usually associated with orgasm and seem more central (although
not necessary) to the process of reproduction. The view that female orgasm is
not necessary for reproductive success fuels a major controversy surrounding
the role of the female orgasm in evolution. Furthermore, whereas orgasm in
females may not be unique to humans, there is no evidence that it is routine
or common in other primates. This leads to another obvious “why” question.
Two of the central figures in this debate were Elizabeth Sherfey and Don-
ald Symons; more recent contributors are Elizabeth Lloyd and David Barash.
After analyzing evidence about female sexuality presented by Freud, as well
as that from the non-human primate record, Sherfey, in her book The Na-
ture and Evolution of Female Sexuality (1972), proposed that female non-human
primates showed an “extraordinarily intense, aggressive sexual behavior and
an inordinate orgasm capacity” that is inherent in human females but that is
shaped and suppressed by culture (Sherfey, 1972: 52). At the time, this view
was indeed a subversive one. It challenged western notions of a passive female
sexuality, but Sherfey attempted to show that female orgasm was closely linked
with reproductive success. For example, she hypothesized that pregnancy fa-
cilitated orgasmic response by enhancing the capacity for vaso-congestion and
strengthening the uterus during orgasmic contractions.
Symons, in The Evolution of Human Sexuality (1979: 90–95), took issue with
Sherfey and felt that the insatiability of females would actually be a deterrent
to reproductive success. In his argument, an insatiable sexuality was more likely
to detract from child-rearing and subsistence activities. In Symon’s scenarios,
females who mated too promiscuously would actually decrease the likelihood
of choice in selecting the father of their child through sheer volume of mates.
According to Symon’s “[t]he sexually insatiable woman is to be found primarily,
if not exclusively, in the ideology of feminism, the hopes of boys and the fears of
men” (1979: 92). For Symons, female orgasm is a by-product of the male orgasm.
Symons’ perspective reflects western concepts of the passive female and
overlooks the evidence of actual female sexual functioning, such as the capac-
ity for multiple orgasms in women. Orgasm in human females is more likely an
extension of the pleasurable sensations associated with coitus in primate fe-
males generally. Citing the role of oxytocin in both orgasm and nursing, Hrdy
(1999) suggests that the pleasant feelings women experience with orgasm may
be a heritage from the obvious selective value of pleasurable nursing of infants.
Certainly. it seems that the pleasure of orgasm is a powerful motivation for
sexual behaviors. Without estrus marking visible fertility, increasing the sheer
quantity of sex in humans is an ideal strategy for offsetting the ambiguity of
concealed ovulation. That it feels good is a crucial element in the motivations
of individuals, be they males or females. We learn how to have an orgasm; it
feels good and we repeat the behavior. Consistent with our goal of examining
behaviors through multiple levels of explanation, a pleasurable orgasm may be
the proximate reward for engaging in sexual activity that occasionally leads
to the ultimate goal of reproduction. Furthermore, recent research suggests
that the pleasure a woman derives from partnered orgasm carries over into the
following day by enhancing positive and decreasing negative mood (Burleson
et al., in press). It seems reasonable to argue that overall good feelings relate to
more positive relations with partners and offspring.
In the book, The Case of the Female Orgasm (2005), Lloyd reviews twenty-one
theories that have been offered to explain its existence and argues that they
all suffer from one of two biases: the adaptationist bias of seeing it as enhanc-
ing reproductive success and the androcentric bias of assuming that male and
female sexuality are the same or similar. She attempts to remove the female
orgasm from its effect on reproductive success and agrees with Symons that it
is a by-product of selection for the male orgasm (similar to male nipples being
a by-product of selection for female nipples) and has no “function” in itself.
Further, she argues that focusing on the reproductive role of the female orgasm
privileges heterosexuality and women as reproducers. David Barash (2005) has
severely criticized Lloyd’s book and argues that the female orgasm has direct
benefits to reproductive success. Clearly, the debate and discussion of this most
interesting phenomenon will not end soon.
Human Evolution: A Synthesis

With the loss of estrus and the accompanying visible genital and chemical
cueing came the capacity for sexual communication through other (non-verbal
and verbal) means. Changes in human ovulation and sexuality are related to
the increased reproductive success of humans. In this way we can clearly see
the biological basis for the unique trajectory of human sexuality. It is rooted
in principles of selection and adaptation, and the ultimate goal of successful
reproduction. These evolutionary factors should not be confused with the im-
mediate cultural factors influencing an individual’s sexuality within specific
cultural contexts, the proximate and ontogenetic factors. The reproductive
capacity of human females exceeds that of our closest relatives. The human
female has a longer reproductive life and a lower birth interval than the chim-
panzee or gorilla and has the potential (without contraception and extensive
breastfeeding) of producing twice as many offspring in her life.
In addition, reproductive success depends on the ability to care for offspring.
An important part of our success as a species has been our ability not just to
bear more young, but to raise them to reproductive age. Here success in indi-
vidual terms is aided by survival and success of important social units such
as the family and community (It Takes a Village and Other Lessons Children
Teach Us, Clinton, 1996). We have argued that early hominid groups may have
been matricentered or female centered and based on the original family unit
of mother and infant, but increasing demands of raising more helpless infants
led to the expansion of this social unit to include fathers, adult male kin, and
unrelated friendly males.
It is not possible to place with certainty the exact time when early hominid
females lost estrus, developed concealed ovulation, and when fathers began to
contribute more than sperm to their offspring. These factors could well have
been related to changes in human populations associated with Homo erectus
around a million-and-one-half to perhaps even 2 million years ago. Naturally
this has some implications that are of keen interest. Without estrus as a signal,
humans have developed through culture an incredible array of ways of commu-
nicating sexual interest to one another—visually, verbally, and non-verbally.
As we shall see as we focus on sex and reproduction through the life cycle,
culture plays a significant role in shaping modern reproduction and sexuality.
Summary
1 The grasping hand, stereoscopic vision, and grooming are adaptations re-
lated to primate arboreal and subsequent terrestrial environments.
2 These adaptations have consequences for modern sexual behavior includ-
ing the importance of touch, feeling, and vision as important components
in sexual attraction.
3 Bipedalism played a critical role in enhancing trajectories begun in asso-
ciation with adaptation to an arboreal niche. With bipedalism, probably,
began trends for the loss of estrus and escalated reliance on communi-
cation and learning. Bipedalism and the consequent enlargement and
development of complexity in the hominid brain were involved in the
evolutionary tradeoff that selected for infant dependency.
4 Human reliance on learning is a significant aspect of our sexuality associ-
ated with the expansion of the neocortex.
5 For humans the social group is vital for survival.
6 As a continuation of non-human primate behavior, humans form a variety
of socio-emotional ties with one another known as bonds; one of the most
basic is adult female–child. Male–male, male–female, and female–female
bonds can be both cooperative and competitive. Both social and biologi-
cal fatherhood, and intimacy are important in most human societies.
7 The human brain is actively involved in human maturation, reproduc-
tion, and sexuality.
8 The loss of estrus for humans enhanced their reproductive success in com-
parison with other primates, in part through its effect on paternity.
9 There are several controversial views on the role of orgasm for female
evolution. Orgasm is important as a reinforcing mechanism because it is
pleasurable. This is critical in a species without estrus. Human females
are unusual in being able to be sexually receptive throughout their cycle.
With humans, because ovulation was concealed, the sheer amount of cop-
ulation would enhance the chance for impregnation. Orgasm is important
in facilitating this.
1 Some people have suggested that the “touch-deprived” nature of contem-
porary American society may explain some inabilities to form healthy
social bonds (e.g., parent–child, male–female). Do you agree? If you agree,
what do you think can be done about it?
2 In what ways would a strong and healthy young woman with a nursing
infant and a four-year-old child compromise her own reproductive success
by engaging in hunting large game? Would the compromises be the same
for her mate and father of her children to engage in this same type of
hunting?
3 Why would males in dozens of societies rank female attractiveness higher
than wealth and women rank the two qualities in reverse order? What do
these preferences have to do with reproductive success?
Suggested Resources
Books
Buss, David M. 1994. The Evolution of Desire: Strategies of Human Mating. New York:
Basic Books.
Ellison, Peter T. 2001. On Fertile Ground: A Natural History of Human Reproduction.
Cambridge, MA: Harvard University Press.
Hrdy, Sarah Blaffer. 1999. Mother Nature: A History of Mothers, Infants, and Natural
Selection. New York: Pantheon Books.
Small, Meredith. 1998. Our Babies, Ourselves. How Biology and Culture Shape the Way
We Parent. New York: Anchor Books.
Websites
American Association of Physical Anthropologists. http://www.physanth.org/.
American Society of Primatologists. http://www.asp.org/.
Human Behavior and Evolution Society. http://www.hbes.com/.
Human Biology Association. http://www.humbio.org/.
4 Introduction to the
Hormonal Basis of Modern
Human Sexuality
Chapter Overview
1 Introduces the hormonal basis of human sexuality.
2 Describes the H-P-G axis.
3 Defines and compares analogous and homologous structures.
4 Distinguishes the sexual and reproductive cycles.
An evolutionary, interspecies perspective for our hominid sexuality was

presented in Chapter 3. This perspective establishes the roots for our bio-
behavioral sexuality as modern humans by connecting us as a species to our
primate heritage through time and space. This connection has been illustrated
in discussions of the shift from estrus to a menstrual cycle, and the role of
intra- and inter-species behaviors such as bonding and orgasm. Modern adult
sexual and reproductive anatomy and physiology, which emphasize hormones,
are introduced in this chapter and discussed in more depth in Chapters 5 and
6. This discussion of hormones also serves as an introduction to exploring
male and female anatomy. Normative physiology and anatomy are assumed
unless specifically stated otherwise.
A basic awareness of anatomy and physiology is important for the following
reasons. First, our modern anatomy and physiology are panhuman, provid-
ing a baseline for understanding human sexuality as a bio-behavioral, psycho-
cultural, and social phenomenon. Since we share anatomy and physiology as a
species, we are able to engage in intra- and intergroup sexual and reproductive
experiences. Second, while biological aspects such as the gamete—the egg or
sperm—production are species-wide, their definition and interpretation are
culture-specific. Different cultures give different meanings to the reproductive
and sexual processes. The behaviors, sentiments, and values attributed to our
anatomy and its functions are culturally defined. For example, female breast
development is a universal secondary sex characteristic. In current US cul-
ture, it is an erotic symbol or sex signal. In many nonindustrialized societies,
breasts are not eroticized, but are seen as functional structures for nursing the
young. This is obvious when one examines rules about breast coverage cross-
culturally. In most places in the United States, it is illegal for a woman (but not
The Hormonal Basis of Human Sexuality 69
a man) to bare her breasts in public due to the sexual connotations. In tropical
areas cross-culturally, women frequently do not cover their breasts while their
genitals, in contrast, are covered. Previous generations of adolescents in the
United States have pored over National Geographic pictorials of bare-breasted,
indigenous women. The ethnocentrism behind this phenomenon is another
issue altogether.
On June 1, 1994, New York State passed legislation that allowed women
to breastfeed their babies legally in public places such as malls, restau-
rants, and stores. Women may also appear bare-breasted on public
beaches in New York. However, the legality of breastfeeding in public or
appearing topless on public beaches if you are a woman is state-specific.
We allow men to go topless in public due to an androcentric, heterosexist

cultural perspective in which we do not see men’s breasts, areolas, and nipples
as erotic.
Another important reason for having an elementary understanding of
anatomy and physiology is that many bio-behavioral aspects of our sexu-
ality build on having a basic knowledge of our bodies. This includes such
components of our sexuality as sexual response and birth control, as well
as the life cycle phenomena of pregnancy and childbirth. In addition, it is
pertinent to have at least a fundamental awareness of human anatomy and
physiology in order to comprehend how recent technological innovations
that affect sexuality and reproduction have impacted us as both individu-
als, members of a group, and as a species. Innovations such as penile im-
plants, Viagra, and other erection-stimulating drugs, prostheses to alleviate
some physiologically based erectile problems, in vitro fertilization (IVF),
gamete/zygote/embryo transplants, gender selection, and sperm banks all
have the potential to alter radically what has evolved as human sexuality
(see Chapter 7).
Definitions of Auxiliary Terms and Concepts

The following terms are essential to understanding sexual and reproductive
functioning. You will find this list of terms useful for reference as you read
about male and female anatomy and physiology (see Figure 4.1).
Adrenal glands: Two small glands, located on top of each kidney. They are
responsible for much of the other gender sex hormone production in males and
females (testosterone in females; estrogen and progesterone in males).
Analogous: Describing structures that share a similar function, such as the
ovaries and testes in gamete (sperm and egg) production.
70 The Hormonal Basis of Human Sexuality
FALLOPIAN TUBE UTERINE TUBE
FIMBRIAE ENDOMETRIUM
OVARY
MYOMETRIUM
VAGINA CERVIX
Figure 4.1 Female reproductive system.

Source: Office of Women’s Health. womenshealth.gov.
Anatomy: Refers to a specific body part or structure.

Androgens: The collective term given to male sex hormones, of which
testosterone plays a major role in sexual and reproductive development and
functioning.
Cerebral cortex (CC): The outer layer of the brain characteristic of humans
and hominids, involved in perception, analytic and logical thought, and
learning.
Endocrine glands: These glands directly release hormones into the blood-
stream. Sex hormones are released by endocrine glands.
Estrogen: The term given to a group of “female” sex hormones found in
post-pubertal males and females. It is largely responsible for primary and
secondary sex characteristic development in girls.
Gonadotropins: Sex hormones. The generic term given to those hor-
mones involved in primary and secondary sex characteristic development and
functioning.
Gonads: Ovaries in the female, testes in the male. The gonads comprise
one-third of the H-P-G axis. They are the primary source of estrogen and pro-
gesterone production in females and testosterone in males.
Homologous: Structures formed from similar embryonic tissue, such as the
ovaries and testes or the clitoris and penis.
H-P-G axis: Hypothalamus-pituitary-gonad axis, which monitors much of
the bio-chemical aspects of human sexuality.
Hormones: Substances released by the endocrine (ductless) glands that af-
fect anatomical development and functioning.
Hypothalamus: An evolutionarily old brain structure found in many spe-
cies including humans, which monitors a variety of body functions.
Physiology: The function of an organ or body structure.
Pituitary (master gland): An organ in the brain which, as one of its func-
tions, releases hormones necessary for sperm formation and egg development.
Primary sex characteristics: Those structures in both the males and
females related to the reproductive cycle (Frayser, 1985) and directly involved
in sexual and reproductive functioning (e.g., testes and ovaries). Their role
in sexual arousal, pleasure, and orgasm is an interaction of anatomical and
socio-cultural influences (e.g., the penis is a sexual and reproductive structure).
The uterus is a reproductive organ that can also be sexual for women who
experience uterine contractions during orgasm.
Progesterone: A “female sex hormone” found in post-pubertal females and
males. It is responsible for the development of certain primary sex character-
istics in the female such as uterine tone and the maintenance of the endome-
trium (the uterine lining). In males, progesterone is involved in sperm motility
(i.e., how fast the sperm move).
Secondary sex characteristics: These structures in both the male and fe-
male are indirectly involved in sexual and reproductive functioning but are
frequently used as cultural markers of physiological sexual maturity and gender
signals (e.g., pubic hair in boys and girls, female breast development, facial
hair and beard growth in the male). These structures often correlate with the
sexual cycle (Frayser, 1985), and can comprise visual cues of sexual attraction
and arousal.
Testosterone: Considered the “male sex hormone,” it is found in post-
pubertal males and females. Testosterone is primarily responsible for the libido
or innate sex drive in people and primary and secondary sex characteristic
development in the male.
Sexual/Reproductive Structure Distinction

A given structure may serve sexual and/or reproductive functions. The vagina
and penis are examples of organs that function both sexually and reproduc-
tively. Sexual structures are involved directly or indirectly in sexual response,
without necessarily having to serve reproductively as well (e.g., clitoris). Re-
productive structures are directly or indirectly involved in reproduction (e.g.,
the vas deferens).
Sexual and reproductive structures correlate with the sexual and reproduc-
tive cycles as proposed by Frayser (1985). These phenomena can be presented
diagrammatically as shown in Figure 4.2. The sexual cycle relates to human
sexual response, attractiveness, and sexual orientation. The reproductive cycle
refers to puberty, fertility, conception, pregnancy, birth, lactation, and meno-
pause. There is overlap in sexual and reproductive cycles and structures. For
example, the penis and vagina are both sexual and reproductive structures;
penile-vaginal (p-v) intercourse has both sexual and reproductive functions.
Sexual Reproductive
cycle cycle
Figure 4.2 Venn diagram: sexual cycle/reproductive cycle.

Source: Anne Bolin with Elon University Department of Instructional and Campus Technologies.
Much of our sexual and reproductive anatomy is analogous and homolo-

gous. On a hormonal, physiological, and anatomical level, men and women
are more similar than different. For example, the gonadotropins, which are
the male and female sex hormones, are found in both post-pubertal men and
women. Tables 4.1 and 4.2 respectively list analogous and homologous struc-
tures and hormones with their functions.
The following formula represents the biochemical basis of human sexuality:
CC + (H-P-G axis) = bio-chemistry of sexuality

CC = cerebral cortex
H = hypothalamus
P = pituitary
G = gonads
Although the cerebral cortex can dominate the functioning of the H-P-G axis
(e.g., perceived unresolved stress can affect the menstrual cycle), for this dis-
cussion we are going to examine the H-P-G axis as it usually works. The H-P-G
axis operates as a negative feedback cycle, similar to a thermostat, where fluc-
tuations in one part of the axis induce hormone releases in other parts of the
axis. Although the hypothalamus and pituitary monitor a number of body
functions, we will focus on their role in sexual and reproductive processes (see
Figures 4.3 and 4.4).
The hypothalamus, located in the parietal or side area of the brain, releases a
hormone called GnRH (gonadotropic releasing hormone), which triggers the
functioning of the pituitary. In humans, the hypothalamus monitors the onset
of puberty in both genders (puberty is also related to cultural, nutritional, and
exercise practices as will be discussed in later chapters). The hypothalamus
also controls the release of pheromones (i.e., sexual scent cues); the release
Table 4.1 Comparative anatomy
Male Female Homologous Analogous Function
Penis Clitoris X Sexual pleasure in both.

Transport of urine and
ejaculate in the male.
Testes Ovaries X X Primary source of same-
sex gonadotropins.
Responsible for production
of sperm in male,
maturation and release of
eggs in female as well as
primary source of estrogen
and progesterone in the
female.
Vas deferens Fallopian X X Transport of sperm in male,
tubes of the egg in female.
Site of fertilization
(conception) in female.
Scrotum Labia majora X Holds the testes and
(scrotal spermatic cord in the
sac) male. Covered with pubic
hair and sexually sensitive
in both male and female.
Penile skin Labia minora, X X Sexual pleasure. Covers
(foreskin) prepuce glans of penis in the
or clitoral male and clitoris in the
hood at female.
juncture
with mons
Glans penis Glans clitoris X Sexual pleasure in both.
Site of urinary meatus in
male.
Penile shaft Clitoral shaft X Sexual pleasure in both.
Contains internal
reproductive/sexual
structures in male.
Urethra Urethra X Transports urine in both
males and females.
Transports ejaculate in
male.
Cowper’s Bartholin’s X Lubricates urethra and
gland gland neutralizes urethral
acidity in male. Function
in female currently not
well understood.
of follicular stimulating hormone (FSH), luteinizing hormone (LH), and

luteotropic hormone (LTH); and affects erogenous zone sensitivity, those
parts of the body that produce sexual arousal when stimulated. It also is part of
the limbic system of the brain which influences our emotions.
Hypothalamus
LHRH
Pituitary
LH FSH
Ovaries
Progesterone Estrogen
Figure 4.3 H-P-G axis graphics for female.

Source: Emanuele, Wizeman, and Emanuele, 1999. PW, March 8, 2021
The pituitary or master gland monitors a number of body functions. Rela-

tive to male and female sexuality, the pituitary gland releases FSH, LH, and
LTH (i.e., prolactin) to stimulate the testes in males and the ovaries in females.
While males and females produce both their own and other gender gonado-
tropins, progesterone and estrogen are categorized as female sex hormones and
testosterone is the male sex hormone.
In examining the functioning of the H-P-G axis specifically, concepts of tonic-
ity and cyclicity are used. Tonic, which refers to male H-P-G axis functioning, is
the ongoing nature of male hormone production and release. Ramey (1973) and
others clearly document the cyclic nature of testosterone over a twenty-four-hour
Hypothalamus
+
LTH
Anterior
pituitary
–
– +
LH FSH
Testes
Testosterone
Figure 4.4 H-P-G axis graphics for male.

Source: Emanuele, Wizeman, and Emanuele, 1999. PW, March 8, 2021
period by noting that testosterone levels in males generally are highest in the
morning. These data do not, however, contradict the general belief that men,
relative to women, experience tonic patterns of testosterone release. These male
patterns are ongoing and continuous from puberty until death, although there is
a gradual decrease in testosterone production in aging men.
Some researchers believe that in the course of one generation, United

States men may produce as much as 50 percent less semen and sperm
(ejaculate) than in 1950. Environmental pollutants are seen as the
possible cause for this decrease (Glenmullen, 1993: 170). Environmental

pollutants are also believed to affect the quality of both sperm and ejac-
ulate (Aitken and Graves, 2002; Aitken, Koopman, and Lewis, 2004).
Defects in sperm can effect fertility and/or increase the chances of fetal
chromosomal abnormalities (Thacker, 2004).
In contrast, hormone release patterns in women are described as more cyclic,

following a rhythmic flow that approximates a twenty-eight-day or lunar cy-
cle. There is, however, variation in this pattern from individual to individual
and within a woman’s cycle. For example, very few women have menstrual
cycles that are consistently the same length each month. This makes birth
control options such as the rhythm method, cervical mucous checks, and
basal body temperature monitoring less reliable than many other options
(see Chapter 8 for a discussion of contraception). The female cycle is defined
as a negative feedback loop, in which fluctuations in one part of the H-P-G
axis influence hormone release in another part of the axis. For example, a
drop in the pituitary-based FSH level in the follicular phase (described in
Chapter 6) of the menstrual cycle triggers the release of estradiol, an estrogen,
from the ovary.
When discussing the release of hormones in the H-P-G axis, particularly
those released by the gonads (ovaries and testes) and the adrenals, we are re-
ferring to endocrine gland functioning. Endocrine glands are ductless, which
means that hormones are released directly into the bloodstream and can be
measured through tests on blood samples. Excess amounts of endocrine hor-
mones are deposited in the urine. Therefore, excess amounts of androgens,
male sex hormones, which are part of the steroids (a group of sex and other
hormones) that some male and female athletes use to rapidly increase muscle
size and strength, can be detected in the urine.
The hormones involved in H-P-G axis functioning that we will discuss in-
clude the pituitary hormones FSH, LH, or ICSH (interstitial cell stimulating
hormone), LTH (prolactin), and the gonadotropins—androgens commonly
referred to as male sex hormones, as well as estrogen and progesterone, fre-
quently referred to as female sex hormones. (See Table 4.2.)
The hypothalamic hormone GnRH (gonadotropin releasing hormone)
stimulates the frontal lobe of the pituitary to release FSH, LH, or ICSH and
LTH in both males and females. FSH, the follicular stimulating hormone, is
released in the follicular phase of the menstrual cycle during which time im-
mature eggs develop in their ovarian follicles or sacs. This is discussed in depth
in Chapter 6. In men, FSH stimulates spermatogenesis or sperm formation in
the seminiferous tubules of the testicles.
Table 4.2 Hormones involved in H-P-G axis functioning
Hormone Comparative function: male Primary Comparative function: female Primary Source
release: male release:
female
Follicular stimulating Stimulates spermatogenesis Pituitary Egg maturation, includes Pituitary GnRH
hormone (FSH) estradiol (an estrogen) stimulation
from
hypothalamus
Luteinizing hormone Maintains interstitial cells of Pituitary Stops egg maturation, Pituitary GnRH
(LH)—interstitial cell testes releases mature egg from stimulation
stimulating hormone ovary, induces release of from
(ICSH) in male androgens at ovulation hypothalamus
Luteotropic hormone Unknown at present; may Pituitary Uterine tone, stimulates Pituitary GnRH
(LTH) (prolactin) be involved in sperm and lactation, promotes stimulation
testosterone production production of progesterone from
hypothalamus
Testosterone Primary and secondary sex Testes Libido, complement to female Adrenal LH stimulation
characteristics, libido primary and secondary sex glands and in pituitary
characteristics ovaries
Estrogen Skin tone, reduces osteoporosis Adrenal Primary and secondary Ovaries FSH stimulation
risk, complement to glands sex characteristics (e.g., in pituitary
primary and secondary sex menstrual cycle)
characteristics
Progesterone Possibly anti-aggressor agent Adrenal Primary sex characteristics Ovaries LH stimulation
glands in pituitary
LH stands for luteinizing hormone. It is the same hormone as ICSH, the
interstitial cell stimulating hormone. LH functions in both the follicular and
luteal phases of the menstrual cycle as will be discussed in depth in Chapter 6.
In the follicular phase, LH serves to stop egg maturation and helps to release
the mature egg from the ovary through triggering androsterone, a male sex
hormone. In the luteal phase, LH stimulates the release of progesterone from
the follicle or sac that released the mature egg.
In men, LH is also referred to as ICSH. ICSH maintains the cells of the
testes, which produce testosterone, the primary male sex hormone. These in-
terstitial or leydig cells are necessary for testosterone production, which is re-
sponsible for primary and secondary sex characteristic development in males
as discussed in Chapter 5.
LTH or luteotropic hormone (prolactin) is another pituitary hormone in-
volved in the H-P-G axis. It is involved in lactation (breastfeeding), in the
maintenance of uterine tone, and in the production of progesterone. The func-
tion of LTH in the human male is currently unknown.
This chapter is a brief overview of the hormonal basis of human sexuality.
The specific hormones introduced here will be discussed in more detail in the
next two chapters. Those chapters will integrate these hormones into male
and female sexual reproductive anatomy and physiology.
When the limbic system, which is the center of our emotions and includes
the hypothalamus, is added to the CC + H-P-G axis formula, we have a com-
plete bio-chemical basis for human sexuality. These brain functions interact
to comprise the cognitive, affective, and biochemical foundation of human
sexuality. This basis is expressed through the physiological maturation and
development process. It includes attainment of puberty, and the learned, cul-
turally specific behaviors, values, norms, and beliefs we as a species believe
and act on verbally, nonverbally, and symbolically. The latter include each
culture’s shared definitions of masculinity and femininity, appropriate gender
role behavior, speech, demeanor, and affect, as well as rules concerning what
constitutes “normal” sexual, and reproductive behaviors. Hormones and be-
havior affect each other (this interaction will be illustrated in the next few
chapters). The manifestations of hormones and of the physical characteristics
they influence occur within a cultural context. The next three chapters dis-
cuss biological traits such as the onset of puberty, regular menstrual cycles,
and the sexual and reproductive structures as they are expressed within the
context of culture.
Summary
1 The cerebral cortex plus the H-P-G axis comprise the bio-chemical and
behavioral bases of our sexuality.
2 The hypothalamus, an evolutionarily old structure, and the pituitary
gland make up the bio-chemical regulators of our sexuality.
3 The H-P-G axis comprises a negative feedback system that influences the
onset of puberty, the release of gonadotropins, the release of pheromones,
and erogenous zone sensitivity.
4 Many of our sexual and reproductive structures are both analogous and
homologous. Men and women share a hormonal system. This means that
bio-chemically, men and women are more similar than they are different.
5 The sexual and reproductive cycles are distinct but overlapping systems.
6 Male hormonal functioning is frequently described as tonic, female as
cyclic.
7 The major sex hormones are androgens, specifically testosterone; estro-
gen, which refers to a group of hormones; and progesterone.
8 Culture and biology interact in the expression of our sexuality.
1 How do biology and culture affect each other?
2 If men and women share a hormonal system, what accounts for the differ-
ences between men and women?
Suggested Resources
Journal
Aitken, R. John, Peter Koopman, and Sheena E. M. Lewis. 2004. “Public Health:
Environmental Pollution and Male Fertility.” Nature, 432: 48.
Website
Endocrine Society. https://www.endocrine.org/about-us. Last accessed 10/2019.
5 Modern Human Male
Anatomy and Physiology
Chapter Overview
1 Applies the formula CC + (H-P-G axis) = bio-chemical behavioral aspect
of human sexuality to males.
2 Discusses the role of FSH (follicular stimulating hormone) and LH
(luteinizing hormone)/ICSH (interstitial cell stimulating hormone) as a
tonic process in males.
3 Discusses the external and internal anatomy and physiology of the male
sexual and reproductive systems.
4 Discusses male primary and secondary sex characteristics.
5 Introduces the concept of the libido and relates it to testosterone levels.
6 Discusses the effect of alcohol and marijuana use on testosterone levels.
7 Introduces HIV infection and AIDS in men.
8 Introduces male sexual response.
In this chapter (and in Chapter 6), physical normalcy is assumed unless specif-
ically stated otherwise. A discussion of male anatomy incorporates the CC +
(H-P-G axis) formula presented in the previous chapter.
Applying the CC + (H-P-G axis) formula to males involves a hormonal
exploration of FSH (follicular stimulating hormone); LH (luteinizing
hormone)/ICSH (interstitial cell stimulating hormone), which are the
same hormones; and the gonadotropins, particularly the androgens. As
introduced in Chapter 4, men tend to have a more continuous (tonic) re-
lease of H-P-G axis hormones in their bodies than do women, whose more
rhythmic release is described as cyclic. Men’s hormonal patterns continue
from puberty until death. In men, the hypothalamic release of GnRH (go-
nadatropic releasing hormone) triggers pituitarian FSH and LH (ICSH)
activity. FSH and LH activate testicular functioning and the production
of androgens, male sex hormones. FSH aids in spermatogenesis, or sperm
production, which occurs in the seminiferous tubules of the testicles. LH
(ICSH) maintains and promotes the integrity of the interstitial cells of the
testes, the major source of testosterone production. Testosterone, consid-
ered a “male” sex hormone, is the primary androgen and the focus of our
discussion.
Modern Human Male Anatomy and Physiology 81
Testosterone is produced in the interstitial cells of the testicles in men. An-
other name for the interstitial cells is the leydig cells. In women, much of the
testosterone is produced in the adrenal glands with some of it also produced
in their ovaries. Testosterone is a crucial sexual cycle hormone in both genders
and a reproductive cycle hormone in males. On a hormonal basis, testosterone
is responsible for the libido or sex drive in both men and women. The amount
of testosterone required to maintain the libido in men and women is referred
to as the threshold level, and it exists in roughly the same amounts in both
men and women. As long as this threshold level is maintained, the hormonal
aspects of the libido are present in men and women. Men and women pro-
duce testosterone from puberty until death. Thus, both men and women can
maintain a hormonal basis for the libido from sexual adulthood (i.e., puberty)
through sexual and reproductive aging (e.g., post-menopause in women).
Testosterone, as a major sex hormone, is actively involved in the expres-
sion of primary and secondary male sex characteristics. For this to occur, men
continuously produce, from puberty until death, about ten times as much tes-
tosterone on a tonic basis as do women (Greenberg, Bruess, and Mullen, 1993).
Generally, the tonic release of free circulating testosterone in the male sup-
presses or binds the release of estrogen and progesterone, the “female” sex hor-
mones, in the male. The primary sex characteristics are those directly related
to sexual and reproductive functioning. In the male, they include the growth
and development of the internal and external penis, the testes and scrotal sac,
as well as the auxiliary reproductive structures such as the vas deferens, semi-
nal vesicles, and epididymis.
Secondary Sex Characteristics

The secondary sex characteristics are those features less directly involved in
reproductive functioning, but generally highly involved in sexual functioning.
Testosterone-induced male secondary sex characteristics include a number of
features. It is important to remember that these are general patterns and a lot
of normal individual variation exists within these patterns. These features are
relativistic, not absolute, between genders. For example, as with the rest of
the primate world, generally human males are taller, more muscular, and have
more facial and body hair than do females. Sex hormones also interact with
genetic and cultural variables, which result in adult characteristics (e.g., height
has a genetic, hormonal, and cultural basis). Genetic tendencies to be tall or
short are reinforced by hormonal release that promotes bone growth and later
closes the epiphyses, which are further influenced by such cultural practices as
nutrition.
Secondary sex characteristics involve structures that often are culturally de-
fined as visual sexual and gender cues and indicators of sexual adulthood. Since
spermatogenesis is invisible compared to the visibility of menstruation, the ap-
pearance of secondary sex characteristics in the male can be used culturally to
define sexual and reproductive adulthood in men. This illustrates how physiology
82 Modern Human Male Anatomy and Physiology
can be culturally integrated and interpreted on a behavioral and attitudinal
level. For example, the production of testosterone results in beard growth that
can be used to define masculinity and manhood. In the United States, a boy’s
physical ability to produce facial hair is symbolically and behaviorally recognized
as a sign of becoming a man. Shaving or plucking male facial hair is a cultural
response to a secondary sex characteristic. It can serve as part of grooming and
hygiene in the Euro-American, European, and Native American cultures.
Cross-culturally, there is a lot of variation within and between groups.
Blondes tend to be the hairiest of people, while Africans, Asians, and Na-
tive Americans have less facial and body hair. Even within specific kin groups
there are individual variations. The pattern and distribution of male facial
hair, overall body hair, and pubic hair are a function of testosterone. Beard
growth, and the male hairline shape, but not the amount of head hair,1 are
the functions of testosterone. Men tend to have a scallop-shaped hairline as
contrasted to the women’s which is more ovoid.
In addition, the diamond-shaped pubic hair patterning in men as compared
with the inverted triangle pattern in women is related to testosterone. As with
women, men’s pubic hair varies in color and amount with the individual and is
subject to the aging process. Generally, it is curly, soft, and sensitive to sexual
stimulation.
Although also a function of genetics and cultural practices regarding nu-
trition, exercise, and bone development, height and bone growth are related
to testosterone. Generally, men are taller than women, with longer, heavier,
and denser bones. This also allows them to have greater physical strength and
speed than women.2 The combination of testosterone and estrogen also puts
men under seventy years old at a lower risk for osteoporosis, a degenerative
bone disease common in older women.
The enlargement of the larynx that deepens the male voice is one of the
non-reversible secondary sex characteristics. The enlargement of the larynx
and changed voice are permanent, even if testosterone ceases to be produced.
In male castration or orchidectomy, the testicles are removed. This happens,
for example, as a treatment for some testicular cancer. The male castrati who
sang in choirs during the Middle Ages were castrated prior to puberty. Castra-
tion also meant that their overall bone size was smaller. Their chest bones were
less well developed than non-castrati, which contributed to a higher voice.
Castrati had smaller penises and did have active sex lives. Although testos-
terone is responsible for the sex drive (interest in sex) and reproductive male
sex characteristics such as the production of sperm and semen (ejaculate), it
is not responsible for erections or feelings of sexual pleasure per se. If this is
confusing, remember that fetal and prepubertal boys are capable of erections.
Prepubertal boys are also capable of masturbation, feeling sexual pleasure, and
having an orgasm; they do not, however, ejaculate. Castrati tended to lead
charmed lives. According to Henderson (1969), the fortunate few boys se-
lected as castrati would have the choicest food, clothes, homes, and women at
their disposal for the length of their careers. Castrati were not perceived with
the same kind of horror that we perceive them in retrospect (Bullough, 1976;
Davis, n.d.b; Rice, 1982).
Eunuchs, also castrated and often after puberty, reflect feminized fat
distribution. They were found in the harems in the Middle East and
ancient China to prevent wives and concubines from having affairs with
other men or from other men having access to these women. Their lack
of testicles was culturally believed to sufficiently decrease their libido so
that they would have no sexual interest in the women they were guard-
ing. Depending on the situation, however, they may have formed deep
personal and emotional attachments to the women they guarded.
Men generally also have more muscle mass,3 are leaner, and have a lower body
fat to overall body mass ratio than women. This contributes to men’s overall
greater physical strength. In current US standards of aesthetic leanness for men,
the range of body fat is from about 8 percent for athletes to about 19 percent for
the “average” male (“Defining Overweight and Obesity,” 2005). Males need a
minimum of 4–6 percent body fat to reach puberty. Athletes in training, football
players for example, may try to achieve a 4–6 percent body fat content during the
playing season. They may be muscularly “bulky,” but they are not soft-tissue fat.
Men tend to have upper-body fat (i.e., their body fat is distributed around
their waists and chests). Some physical aspects of men’s comparative leanness
and body fat distribution are that men tend to carry “spare tires,” “love han-
dles,” or “pot bellies” of excess body fat around their midsections; they may
be more prone to coronary heart disease; and they may float less easily than
women. In general, both men and women have become fatter since the 1980s;
both have greater amounts of subcutaneous body fat than previously (“Defin-
ing Overweight and Obesity,” 2005).
For some types of prostate cancer, female sex hormones are given to slow
or stop tumor growth. Depending on the type, amount, and duration of
this form of chemotherapy and the individual man’s hormonal system,
he may develop some female secondary sex characteristics during treat-
ment. This could include changes in body fat amount and distribution
and breast enlargement.
Testosterone has an effect on men’s skin. Men’s skin tends to age more slowly,
has fewer wrinkles, and is more prone to acne than women’s. Men tend to have
more severe acne than do women because testosterone can stimulate sebaceous
(oil) gland secretions which contribute to acne. Skin smoothness and aging are
also related to the estrogen levels that men retain from puberty until death, as
well as cultural practices such as shaving, which removes dead skin cells.
Libidinous functioning or having an interest in sex has attributes of both
primary and secondary sex characteristics. As stated previously, a compara-
ble amount of testosterone known as the threshold level is required in both
males and females in order to generate an interest in sex. Again, this baseline
physiological level integrates with cultural values and beliefs about how, when,
where, with whom, and how often the sex drive is expressed.
Estrogen and progesterone in men are primarily produced in the adrenal
glands and generally are suppressed or bound by the testosterone. Unbound
estrogen can produce secondary feminizing sex characteristics such as gyneco-
mastia or breast development, loss of facial and body hair, or reduced sex drive.
Progesterone, which does not produce feminizing secondary sex characteris-
tics in men, may be given in various forms to some convicted sex offenders. It
is part of their rehabilitation and therapy, as it acts as an antilibido hormone. It
not only diminishes libido in both males and females, but may mitigate aggres-
sive feelings as well. Silber (1981), a researcher in this area, has administered
progestin-based drugs to some convicted sex offenders who have chronically
elevated testosterone levels.
Silber (1981) investigated male sexuality and has developed a theory about
certain kinds of sexual behavior related to hyper-testosterone levels. The nor-
mal level of free-circulating testosterone found in men allows for primary and
secondary sex characteristic development and a sex drive. A few men, however,
have chronically elevated levels of testosterone well outside the normal range.
These chronically elevated levels of testosterone, coupled with strongly inter-
nalized and culturally supported values on aggression and violence as a means of
expressing anger and frustration or resolving conflict, may be involved in some
of the more dramatic sex crimes. Silber hormonally tested and interviewed a
number of men convicted of sex crimes, which also involved extreme forms of
violence (e.g., rape and body mutilation or dismemberment). In this sample, he
found chronically elevated levels of testosterone, a psychological connection
between thoughts of sexual violence and heightened arousal, and acceptance
of physical violence as a means of expressing anger or frustration and resolv-
ing conflict. When these men in his prison sample were given progestin-based
drugs, their testosterone levels lowered to within normal limits. The testoster-
one levels remained within normal limits as long as the progestin-based drug
was taken. If the drug regimen stopped, the testosterone levels increased to
their previously elevated levels. On the drug, the prisoners reported less of a
connection between sexual arousal and violence (Silber, 1981).
This is fascinating and potentially powerful research that has controver-
sial and potential social and legal implications. Although some Scandinavian
countries physically castrate convicted male sex offenders, this is seen as cruel
and unusual punishment in the United States. More likely, convicted male sex
offenders in the United States will be given progestin-based drugs (Gis and
Gooren, 1999; Grossman, Martis, and Fichtner, 1966).
Drug usage can affect male sex hormones, particularly testosterone. Two
commonly used drugs that affect testosterone levels are alcohol and marijuana.
Extensive chronic alcohol and marijuana abuse can suppress testosterone lev-
els below the threshold level. This can result in loss of libido and the ap-
pearance of feminizing secondary sex characteristics such as gynecomastia, or
breast enlargement, increase in overall amount and redistribution of body fat,
body hair loss, and beard softening. These effects are reversible if the alcohol
or marijuana drug abuse stop. Some recent research suggests that chronic drug
use or abuse by men can negatively affect both their fertility and the quality
of their sperm as well as contribute to problems in fetal development (Daniels,
1997; Emanuele and Emanuele, 1998).
Steroids also affect secondary sex characteristics, particularly muscle size
and the lean muscle mass to body fat ratio. Steroids contain androgens that
can rapidly increase muscle mass. Their use for this purpose is illegal in most
formal athletic situations. The 2004 Summer Olympic Games and the Amer-
ican Baseball Association have both had to address scandals involving steroid
use by their players (Anon., 2005). Steroids are stored in the body for at least
six weeks and excess amounts are secreted in the urine. This phenomenon
explains the mandatory urine tests for steroids in competition-based athletes
and for some employees. Steroids also can cause general metabolic problems.
They are powerful and potentially dangerous drugs. If abused they may damage
the kidneys, liver, and heart, or even result in the user’s death. Injection of
them through shared needles also puts the user at risk for hepatitis B, for HIV
infection, the virus which causes AIDS, and for other infections.
Primary Sex Characteristics

Primary sex characteristics are those features in men and women that are
directly involved in sexual and reproductive functioning. In men, they are
hormonally controlled by the androgens or male sex hormones. Testosterone
is the major gonadotropin involved in the growth and development of these
characteristics.
The penis, which increases in size at puberty, is composed of internal and
external structures. The external penis includes the glans, shaft, and crura or
root, structures which are homologous to the female’s clitoris. The glans of
the penis, illustrated in Figures 5.1 and 5.2, is acorn-shaped and is formed by
the internal corpus spongiosum. The corpus spongiosum also contains the
urethra, which ends in the glans at the opening called the urinary meatus.
The glans or head of the penis is hairless and is extremely sensitive to sexual
stimulation. It is covered with penile skin called the foreskin.
In some cultures, including often in the United States since about 1850,
males have their foreskins surgically removed in a procedure known as cir-
cumcision. Male circumcision is not universally practiced. Nonindustrialized
societies that practice circumcision usually do it for social and symbolic rea-
sons relating to status changes in males. Doctors in the United States orig-
inally performed circumcisions to reduce masturbation. Currently, about 65
percent of boy babies in this culture are circumcised, often without anesthesia,
Penis with Penis without

foreskin foreskin
Foreskin
Figure 5.1 Penis—with and without foreskin.

Source: Shah, Soavrin M. MedlinePlus. US National Library of Medicine. www.medlineplus.
gov/ency/imagepages/19093.html.
Figure 5.2 Male internal reproductive sexual anatomy.

Source: Wikipedia. By Male_anatomy.png: alt.sex FAQderivative work: Tsaitgaist (talk)—
*[[:File:Male_anatomy.png|Male_anatomy.png], CC BY-SA 3.0, https://commons.wikimedia.
org/w/index.php?curid=6569849.
within two days of birth for social reasons, which have been given medical and
hygienic explanations. These include reduction of body odor from accumula-
tion of smegma, possible reduction for risk of HIV infection, increased sexual
sensitivity, and to be “like the other boys.” Since the early twenty-first century
in the United States and elsewhere, circumcision has become a controversial
practice whose medical rationale is certainly suspect (“Trends in Circumci-
sions Among Newborns,” 2005). The controversies surrounding male circum-
cision in nonindustrialized societies to prevent heterosexual transmission of
HIV will be discussed in Chapter 16 (See Figures 5.1 and 5.2).
At the base of the glans penis where the head of the penis and the shaft
meet is the frenum or frenulum. This small structure is somewhat triangular
in shape, sensitive to sexual stimulation, and is the place where the foreskin
attaches to the glans. At either side of the frenulum are the preputial glands,
which secrete smegma. Smegma is a waxy, lubricating substance that allows for
smoother retraction of the foreskin over the glans. With circumcision, smegma
no longer collects under the foreskin. In contrast to industrialized societies,
some Islamic, Middle Eastern groups and Polynesians are meticulous about
male genital cleanliness and see men in Europe and the United States as dirty
by comparison (Bullough, 1976; Marshall and Suggs, 1971).
The shaft is the body of the penis that is covered with relatively loose, hair-
less skin. The shaft contains the corpus spongiosum and corpora cavernosa or
cavernous bodies. The shaft increases in size and firmness during arousal as the
cavernous bodies engorge with blood to create an erection. The shaft is sensi-
tive to sexual stimulation. Its size, erectile ability, connection with sexuality,
and fertility are of great cultural interest in the United States and elsewhere.
In this culture, penis size is of major concern to men regardless of their sexual
orientation. In some other cultures, genital surgery on the shaft such as subinci-
sion, an incision on the underside of the penis, or superincision, an incision on
the ventral (top) side, is performed to heighten men’s sexuality, their masculin-
ity, or as an indication of status change from boyhood to manhood. These pro-
cedures will be discussed in more detail in the chapter on adolescence (Chapter
11). The crura or root forms the base of the penis and can be felt externally as a
ridge at the point where the penis attaches to the body at the lower abdomen.
The scrotal sac or scrotum is a multilayered pouch of loose skin located
behind the penis that contains the testicles, epididymis, and spermatic cords.
The scrotal sac generally is hairless and is sensitive to sexual stimulation. It is
homologous to the labia majora in females.
From the base of the genitals to the anus is an area of skin in men and
women called the perineum; in men the perineum extends from the scrotal
sac to the anus. The perineum is soft, generally hairless, and sensitive to sexual
stimulation. Stimulation of the prostate gland through the perineum or anally
can be highly erotic for many men (Ladas, Whipple, and Perry, 1982).
The testes or testicles, derived from the Latin testare (meaning to testify), are
two spherical spongy bodies located in the scrotal sac. They are homologous and
analogous to the female’s ovaries. They are mobile in the scrotal sac. Testicles
can be elevated or lowered in the scrotal sac in response to such factors as tem-
perature, surprise, or fright. The ability of the testicles to move in the scrotum
contributes to reproductive success. Retraction of the testicles in response to a
threat may preserve them. Since sperm can only exist at temperatures of about
32°C, having sperm produced outside the body cavity helps to ensure their
survival. In addition, retraction and extension of the testicles in response to
external temperature maintains the proper temperature for sperm production
and survival. Many men have experienced this when diving into a cold body of
water and feeling their testicles retract toward their body. Most simply, the tes-
ticles, which may rest unevenly in the scrotum, are the site of spermatogenesis.
The internal construction of a testicle is composed of tightly coiled tubes called
seminiferous tubules and a cellular arrangement resembling either a sponge or
honeycomb. This cellular arrangement is referred to as the interstitial cells or
leydig cells. They are the source of testosterone. The production of testosterone
is influenced by the release of FSH and LH from the pituitary gland. LH acts
directly on the leydig cells to maintain their integrity so that testosterone can
be produced and secreted. FSH also acts on the formation of sperm in the sem-
iniferous tubules. Testosterone release is continuous from puberty until death,
as is sperm production, though both diminish in quantity as men age. Millions
of sperm are produced in the seminiferous tubules each day from puberty until
death. They are produced in an immature state and are matured outside the
testicle, in contrast to the mature egg released by the ovary.
Testicular cancer is most commonly found in men in their twenties. As

a means of early diagnosis of testicular cancer and as a means of main-
taining a man’s overall andrological health, regular testicular self-exams
(TSEs) are encouraged. They need to be performed regularly and con-
sistently, and are analogous to breast self-exams (BSEs) in women. TSEs
are most effective after a warm shower, when the scrotal sac is relaxed
and the testicles are descended. Visual examination to detect changes in
color, size, shape, or to note the appearance of lumps or growths is done
first. Then, the man is encouraged to gently palpate (feel) the testicles
and spermatic cords, initially to familiarize himself with his own anat-
omy, and secondarily to feel for any unusual lumps or changes. Please
note, for many men, one testicle rests lower in the scrotal sac than the
other. This is an anatomically common occurrence.
From the seminiferous tubules, the newly produced immature sperm cross the
testes to the epididymis. The epididymis are two, crescent-shaped, grayish struc-
tures that curve around the side of each testicle. They house the immature
sperm for approximately seventy-two days until they are sufficiently mature
to be released into the vas deferens (Daniels, 1997; Emanuele and Emanuele,
1998). It is important to remember that the manufacture and maturation pro-
cess of sperm is continuous. Millions of sperm are produced and matured daily.
The spermatic cords, located on the side of each testicle and extending to
the pubis, contain several structures such as the cremasteric muscle, vas def-
erens, blood vessels, and nerves. The spermatic cord itself functions to raise
and lower each testicle in the scrotal sac. The difference in the length of the
spermatic cords is the reason that one testicle may hang lower in the scrotal
sac than the other testicle. The elevation and lowering of the testicle in re-
sponse to changes in temperature, fright, stress, or sexual arousal is a function
of the cremasteric muscle. The actual response of the cremasteric muscle is
called the cremasteric reflex. This reflex can be triggered spontaneously by
running the side of one’s thumb quickly along the inner thigh of an unsuspect-
ing male. The testicles will spontaneously contract. Triggering this response is
not recommended unless you know the male well.
Another structure located in each spermatic cord is the vas deferens. The
vas deferens, analogous and homologous to the fallopian tubes, transport the
mature sperm from the epididymis out of the pelvis to the seminal vesicles
and ejaculatory tracts or ducts. Release of mature sperm by the epididymis
into the vas deferens is continuous. However, during times of intense sexual
arousal, an average of 200–400 million sperm are released into the vas defer-
ens. The vas deferens begin as external structures in the spermatic cord and
then proceed internally to loop around behind the bladder until they join with
ejaculatory tract on each side of the man’s body. The vas deferens are the site
of a vasectomy, the most common form of voluntary male sterilization (see
Chapter 8 for a description of this procedure).
After looping around behind the bladder, the vas deferens connect with the
seminal vesicles. There are two of these structures as well, on each side of the
man’s body, adjacent to the bladder. The seminal vesicles produce the majority
of semen.
After the vas deferens loop around the bladder joining the seminal vesicles,
the vas deferens become the ejaculatory tract. The sperm carried by the vas
deferens now becomes part of the ejaculate when the seminal vesicles release
semen into the ejaculatory tract and the semen mixes with the sperm to form
ejaculate.
The tract contains ejaculate from the point where the vas deferens becomes
the ejaculatory duct. By volume, ejaculate is about 98 percent semen and
2 percent sperm. Semen is a pearly-colored, sticky, viscous fluid that leaves a
white stain on material such as clothing or bedding when dried. It will, however,
wash out of clothing or bedding. Semen is essential to sperm for transport and
survival. Semen is an alkaline or basic substance with a pH range from 7.5 to 9.5.
Sperm needs an alkaline environment in order to survive (Guylaya et al., 2001).
Semen is composed of a number of ingredients including albumen, the same
substance found in egg whites, which gives semen its slippery texture; it also
has sugars—glucose and fructose; bases, which give it its salty taste; and pro-
teins (Guylaya et al., 2001). Semen has several functions. Its composition nour-
ishes the sperm. Semen also is a transport medium for the sperm, aids in sperm
motility, and lubricates the urethra. The amount of ejaculate per expulsion
averages about two teaspoons, although it may feel and appear to the male and
his partner(s) to be a great deal more.
Currently, with the very real concern and problem with HIV transmis-
sion through semen and vaginal fluids, oral sex on either a man (fellatio) or
woman (cunnilingus) is only a safer sex activity when using a condom on
the penis or vaginal dam barrier over the vulva, the external genitalia, of
the female. The HIV virus is found in semen, not sperm (IXth International
AIDS Conference, 1993; Griffin, 2005; Menstuff, 2005; Padian, 1987). On
the risky sex continuum, HIV exists in sufficient quantities in semen to in-
fect a partner through unprotected penile-anal, penile-vaginal, or oral sex
(IXth International AIDS Conference, 1993; “Advancing HIV Prevention,”
2003). Therefore, properly used latex barriers such as condoms and vaginal
(dental) dams need to be consistently used to reduce the risk of infection
(see also Chapter 16).
Semen also has socio-cultural dimensions. In many cultures it is recognized
as a vital life substance. There are a variety of beliefs about its functions,
quality, and quantity. Barker-Benfield (1975) has coined the term “spermatic
economy” to connote the attitudes of some Mediterranean groups and the
nineteenth-century British toward “semen” (sic) (i.e., ejaculate). In these cul-
tures, ejaculate is seen to exist in finite supply and judicious caution against
“spending” (i.e., ejaculating “frequently,” as with masturbation) is advised.
Until the present generation, among the Sambia, a patrilineal, horticultural
group in New Guinea, prepubescent and adolescent boys ritually engaged in
fellatio (oral sex) in order to build strength and physical reserves of ejaculate
so that they do not run out of it in adult heterosexual relations (Herdt, 1982;
Knauft, 2003). Among the Sambia, women are seen as sexually powerful and
voracious. Ejaculatory contact with women is carefully regulated so as not to
use up all of a man’s vital life essence (see also Chapter 11).
We have mixed views on the wisdom of frequent ejaculation or “spending”
in our culture. One philosophy promotes a “use it or lose it” approach; the
more orgasmic (ejaculatory) one is, the more one will continue to be (Masters
and Johnson, 1974). The other approach, exemplified by some college ath-
letic coaches from the late-nineteenth century to the present, encouraged a
“spermatic economy” perspective. Male athletes were advised not to engage in
ejaculatory sex before an event so that they would “save” their strength and
energy. Although many college coaches in the United States recognize this as
a piece of folklore, and most do not pass it on as serious advice to their players
(Gordon, 1988), athletes in a human sexuality class state that they are told by
their coaches to avoid having “sex” before a game to avoid “being tired.”
The ejaculatory tract is essentially an extension of the vas deferens. The
ejaculatory tract transports the ejaculate (i.e., sperm and semen) to the ure-
thra. The urethra is surrounded by the prostate, which produces the balance
of the semen to deposit a full ejaculation in the urethra.
The prostate is a walnut-shaped, spongy organ that lies below the bladder.
The urethra runs through it. The prostate can be felt through the perineum
and by finger insertion into the rectum. Perineal and rectal stimulation of the
prostate can produce intense levels of sexual arousal. The prostate produces
semen that contributes to the ejaculate carried in the ejaculatory tract. The
prostate is a common site of both minor irritation and major problems. In
younger men, prostate trouble can be due to either localized or systemic in-
fection or irritation and is known as prostatitis. This can generally be easily
remedied through antibiotics. In older men, enlargement of the prostate due
to either atrophy as part of the natural aging process or due to prostate cancer
commonly occurs. Prostate cancer currently is most reliably diagnosed by a
combination of a PSA blood test and digital rectal exam (Oesterling, 1991:
24). It occurs in a geometric proportion relative to age: in fifty-year-old men,
there’s a 40 percent chance of enlargement; in sixty-year-old men, a 50 percent
chance and so forth. It’s pretty much a given that the longer a man lives, the
greater are the chances that he will have problems with his prostate. One of
the more serious immediate concerns of an enlarged prostate, either due to
irritation, atrophy, or cancer, is that the enlargement constricts the urethra.
Constriction of the urethra makes urination painful, difficult, or impossible.
In fact, painful, slow, or incomplete urination is frequently a sign that prostate
problems exist. Treatments include antibiotics, or in the case of enlargement
or cancer, surgical removal of the prostate often happens. For benign, non-
cancerous prostate enlargement, drug treatments, laser therapy, or a TURP is
performed. TURP stands for transurethral resection of the prostate. A man
does not ejaculate after a TURP, but should retain erectile and orgasmic abil-
ity. For prostate cancer, a number of treatments are available. These include
more radical surgery, radiation, hormone therapy, chemotherapy, or “watchful
waiting,” depending on the location, size, and type of the tumor (Carroll and
Nelson, 2004). An orchidectomy, or removal of the testicles, may be performed
in some cases of prostatic cancer to avoid testosterone feeding the cancer.4
The male’s urethra runs from the base of the bladder through the corpus
spongiosum, the underside cylinder of the internal penis, ending in the uri-
nary meatus at the glans of the penis. The male urethra has two functions. It
transports urine from the bladder to outside the body, and it transports the
ejaculate, which is deposited in the urethra during the emission phase of male
ejaculation, from the ejaculatory tract and prostate to outside the body. Both
urine and ejaculate leave the body through the urinary meatus.
As stated previously, sperm survive in an alkaline or basic environment.
Urine is acidic and the urethra can be acidic from transporting urine. To coun-
teract the acidity of the urethra so that sperm can survive, two phenomena
occur. There is a sphincter or small closure between the bladder and urethra.
This sphincter closes during arousal and ejaculation so that urine does not
leak into the urethra and damage sperm. The common belief in the United
States that one may swallow urine when swallowing ejaculate, “cum,” during
oral sex is therefore erroneous. Again, it is important to remember in this age
of AIDS, that oral sex is risky without using a condom from beginning to end;
with a condom oral sex becomes safer.
Some yogis, practitioners of Tantrism, a sensuous form of yoga, and Robert

Noyes, the founder of the Oneida Community, a religious sect started in
the nineteenth century near Oneida, New York, claim to be able to attain
conscious control over the urinary sphincter. They use this discipline as a
part of their birth control.5 By concentrating intently during the emission
phase of ejaculation when the ejaculate enters the urethra, they open the
urethral sphincter and force the ejaculate into the bladder instead of out
through the urinary meatus. This process is called retrograde ejaculation
which also occurs as a side effect of a TURP, discussed previously. It may
also occur as a side effect of taking some major tranquilizers or severe al-
cohol abuse. When the man urinates, the ejaculate is expelled, sometimes
causing the urine to have a milky-white coloration.
To further counteract the acidity of the urethra, secretions from the Cowper’s
glands neutralize acid levels and lubricate the urethra for the passage of ejacu-
late. Cowper’s glands and ducts are located just beneath the prostate on either
side of the urethra. They are homologous to Bartholin’s glands in the female.
They release a clear, slippery fluid known as pre-ejaculatory fluid or “precum”
into the urethra. This fluid flows through the urinary meatus immediately prior
to ejaculation and may be used to lubricate the glans and increase stimulation.
This fluid may contain sperm, semen, or HIV if the man is infected. It is im-
portant, therefore, not to swallow precum, or to have it come in contact with
either the women’s genitals or the anus of either gender in order to avoid pos-
sible HIV infection or conception in the case of heterosexual genital contact.
The internal penis is composed of three cylindrical or corpus bodies: two of
which are the corpora cavernosa, Latin for cavernous bodies, and the corpus
spongiosum, Latin for spongy body (see Figure 5.2).
The corpora cavernosa are the top two cylindrical bodies of the penis. They
are composed of spongy tissue and a rich vascular or blood supply. During sexual
arousal, it is primarily these two structures that engorge with blood to create
an erection. In addition to neural responses, an erection is achieved and main-
tained vascularly as long as the blood flow into the corpora cavernosa occurs
faster than the blood flow from it; this process is helped by sphincters which
close to keep the blood in the cavernous bodies. Human males do not have a
penis bone or other structure to maintain an erection. One drug known to have
an effect on the vascular structure of the corpora cavernosa is nicotine. Nicotine
constricts blood vessels. Since free-circulating blood is physiologically import-
ant in achieving and maintaining an erection, smokers and chewers may have
impaired full erectile ability. People who have stopped smoking or chewing to-
bacco and whose bodies are nicotine-free report quicker, fuller, firmer erections
(Buffum, 1982). Lack of nicotine allows the blood vessels of the penis to open
more completely. Chapter 12 discusses other drugs that can affect erectile ability.
The third cavernous body of the internal penis is the corpus spongiosum.
The corpus spongiosum forms the glans penis and is the structure through
which the urethra runs ending in the urinary meatus at the tip of the glans.
Men who have been subincised (i.e., who have had the underside of their pe-
nes slit open vertically as part of initiation; see Chapter 11) do not urinate
through the urinary meatus in the glans. Urine is released farther back along
the urethra.
Male internal and external genitalia comprise the sexual and reproductive
structures. The male external genitalia, in contrast to the female’s, are highly
visible. Both internal and external structures operate dramatically during
male sexual response. The distinctions between conscious and unconscious
(out-of-awareness) responses and erection-ejaculation-orgasm are introduced
here and will be discussed in more detail in Chapter 12.
Sexual response, in general, is an interaction of conscious and unconscious
mechanisms. The conscious awareness involves the cerebral cortex, the lim-
bic system (feelings), and to some extent the hypothalamus. It includes the
perceived, learned triggers of arousal, and awareness of excitement or eroge-
nous zone activity. The unconscious dimensions of the hypothalamus, neural
responses such as triggering the reflex arc on the spinal column, hormonal
release (H-P-G axis functioning), and vascular responses. Of these two mech-
anisms, the conscious may dominate, defining pleasure, sensuality, sexuality,
and the perception of the intensity of arousal and orgasm. In the male, this
relates specifically to perceptions of erectile firmness, “staying power” (ability
to maintain an erection), ejaculatory force, sensation, and amount. These are
learned, culturally patterned responses. For example, male Tantrics in India
exert conscious control over ejaculatory release. These learned responses can
override physiological response and ability, as evidenced in the sensual-sexual
arousability and pleasure experienced by people with spinal cord injuries.
Erection, ejaculation, and orgasm are physiologically distinct processes, al-
though they may be perceived as being the same, particularly male orgasm
and ejaculation. The fact that post-pubertal males often achieve orgasm and
the expulsion phase of ejaculation concurrently reinforces this belief and the
sensation that orgasm and ejaculation are the same in males.
Summary
1 The CC + (H-P-G axis) discussed in Chapter 4 was applied to males.
2 FSH and LH are involved in the tonic process of spermatogenesis.
3 Androgens, particularly testosterone, are involved in male primary and
secondary sex characteristic development. The role of estrogen and pro-
gesterone in men was presented.
4 Male internal and external sexual and reproductive anatomy and phys-
iology were discussed relative to normal functioning, the libido, and ef-
fects of alcohol, nicotine, and marijuana use on male libido and sexual
response.
5 It is possible for men to contract HIV infection and other STIs through un-
protected penile-anal intercourse; unprotected penile-vaginal intercourse
(particularly if the women is menstruating); and either unprotected fella-
tio (oral sex on a male) or unprotected cunnilingus (oral sex on a female),
particularly if she is menstruating.
6 Cultural responses to male sexual and reproductive functioning include
such practices as circumcision, subincision, and superincision, as well as
cultural beliefs about sexuality.
7 Common problems of the prostate such as prostatitis and enlargement of
the prostate can occur in men across the life cycle and increase as they
age.
8 Erection, ejaculation, and orgasm are physiologically distinct processes.
1 How does the structure of culture influence how we think about male
sexual and reproductive anatomy and physiology?
Suggested Resources
Book
Joannides, Paul. 2004. Guide to Getting It on. 4th ed. Berkeley, CA: Publishers Group
West.
Journal
International Journal of Men’s Health. Men’s Studies Press.
6 Modern Human Female
Anatomy and Physiology
Chapter Overview
1 Applies the formula CC + (H-P-G axis) to female sexual and reproductive
anatomy and physiology.
2 Describes the cyclic, negative feedback aspects of the female’s H-P-G axis.
3 Compares and contrasts the menstrual cycle and spermatogenesis.
4 Discusses the female’s primary and secondary sex characteristics, includ-
ing those that are homologous and analogous with the male.
5 Describes the four phases of the menstrual cycle as well as cultural
responses to it.
6 Discusses menstrual cramps, menstrual synchrony, and LLPD/PMS.
7 Introduces cultural responses to female anatomy and physiology.
8 Introduces models of female sexual response.
9 Introduces conception and recent western technologies that increase the
chances of conception and gender selection.
10 Summarizes the importance of knowing basic sexual and reproductive
hormones, anatomy, and physiology.
The discussion of female anatomy and physiology parallels that for the male.
On a hormonal basis, the formula and systems are analogous for both gen-
ders: the cerebral cortex (CC) + (H-P-G axis) is involved. On a relative scale,
women’s hormonal systems are described as cyclic. Over a period of time, fre-
quently measured in monthly or lunar cycles, a woman completes one round
of hormone release through the H-P-G axis. By comparison, the male’s relative
tonicity means his pattern of hormone release occurs over twenty-four hours.
To introduce the H-P-G axis in women is to discuss it as a negative feed-
back system. The release of LTH (particularly during lactation), FSH, and
LH from the anterior lobe of the pituitary is related to fluctuating ovarian hor-
mones (i.e., estrogen and progesterone). Analogous to the male H-P-G axis,
gonadotropin releasing hormone (GnRH) is released from the hypothalamus
which stimulates the production of pituitary hormones. Follicular stimulating
hormone (FSH) helps eggs mature in the ovary during the follicular phase of
the menstrual cycle. Luteotropic hormone (LTH) not only helps to maintain
uterine tone and promotes progesterone production but is directly involved in
96 Modern Human Female Anatomy and Physiology
the lactation process. Luteinizing hormone (LH), which is synonymous with
interstitial cell stimulating hormone (ICSH) in the male, helps to release the
mature egg from the ovary, induces androgens at ovulation, and induces proges-
terone production and release in the luteal phase of the menstrual cycle. The
cyclic release of these hormones in the female creates a system of balance and
regularity. Contrary to popular lore in the United States, female hormone pat-
terning is not “raging,” “erratic,” or “uncontrolled.” It is interesting to note the
level of cultural concern regarding women’s hormone release compared to the
relative lack of concern toward that of males. For example, Martin notes that
even medical texts refer to menstruation, menopause, and female hormonal
patterns in negative or injured terms—“degenerative, deteriorated, weakened,
repaired.” Analogous processes for spermatogenesis or other body functions are
labeled more neutrally or even positively—“shedding of the stomach lining,
phenomenon of spermatogenesis” (1987: 47–50). This will be discussed in more
detail when the menstrual cycle and the bio-behavioral dimensions of men-
strual cramps, menstrual synchrony, and late luteal phase disorder (LLPD),
popularly known as premenstrual syndrome (PMS), are presented.
As with males, females produce their own gonadotropins (sex hormones),
as well as those of the other sex (e.g., testosterone). In females, androgens,
or the male sex hormones, are produced by both the adrenal glands and the
ovaries (Emanuele, Wezeman, and Emanuele, 1999). Androgens, particularly
testosterone, are produced from puberty until death in the female. Androgens
are released at the end of the follicular phase of the menstrual cycle in order
to help expel the mature egg from the ovary. The libido hormone, testoster-
one, is produced in roughly the same amounts in men and women to ensure
the threshold level necessary for the sex drive. Women continue to produce
testosterone post-menopausally. Thus, on a hormonal basis, women retain
their libido and capacity for sexual response after menopause. The expression
of post-menopausal women’s sexuality varies cross-culturally. In the United
States, it appears to be less dependent on hormones and more dependent on
the responsibilities and stress women have in their lives and the quality of the
relationships they have with their partners (Kaschak and Tiefer, 2001; Tiefer,
2004). Outside the United States, particularly in foraging and matricentered
societies, for example, as well as in Thailand, post-menopausal women’s sexual-
ity tends to be accepted and the women are sexually active (Brown and Kerns,
1985; Im-em et al., 2002).
Specific female sex ovarian hormones, estrogen (actually a group of
hormones) and progesterone, are primary ovarian hormones produced from
puberty until menopause. Their production and release follow an H-P-G axis
pattern analogous to that of the male. FSH induces estrogen; LH induces pro-
gesterone. As with the male, the use of recreational drugs (such as alcohol,
marijuana, cocaine) and some prescription drugs can affect this release pat-
tern, influencing not only the libido and sexual response cycle, but the men-
strual cycle as well (Buffum, 1982; Emanuele, Wezeman, and Emanuele, 1999;
Gill, 2000).
Modern Human Female Anatomy and Physiology 97
Estrogen and progesterone are responsible for the development of primary
and secondary sex characteristics. As with the male, these characteristics
cover a wide spectrum of individual variation, are relative when comparing
men and women, and are expressed through cultural variables of custom, nu-
trition, and health. Estrogen appears to be more operative than progesterone
in the development of many of the female’s secondary sex characteristics.
Secondary Sex Characteristics

Secondary sex characteristics include hair patterning, skin quality, bone in-
tegrity, breast development, muscle mass, and the amount and distribution
of body fat. Estrogen levels influence the ovoid shape of a female’s hairline,
axillary or underarm hair, and pubic hair growth, and the inverted triangle
shape of her pubic hair. As with the male, pubic hair can be sexually sensitive
to tactile stimulation or serve as a visual sexual cue. It is curly, soft, generally
darker than other body hair, and tends to form an inverted triangle from the
pubis down to the groin or upper inner thigh area. The color, amount, and
vagaries in distribution of pubic and axillary hair are individualized and tied to
cultural and genetic factors. For example, women in some Arab societies pluck
or shave their pubic hair as part of female hygiene practices. In many societies
outside late twentieth-century US culture, women do not shave their axillary
and leg hair. In the United States, shaving or not shaving one’s underarms and
legs may be a political statement, a gesture of femininity and aesthetics, or a
custom of hygiene.
One of the functions of estrogen is to keep skin supple and soft and promote
collagen production, a substance that helps to maintain the integrity of skin
cells. Estrogen and lower levels of testosterone also help to inhibit acne in
women relative to men. Loss of estrogen in menopausal women, lack of facial
hair, and not shaving promotes faster skin aging in women than men. In the
United States, this is capitalized on by a highly profitable market in facial
scrubs, emollients, and plastic surgery.
In general, women’s bones are shorter, lighter, and less dense than men’s.
This is due in part to heredity and cultural factors related to diet and exercise,
but it is also due to the ratio and release of estrogen relative to testosterone in
a woman’s body. The loss of estrogen at menopause also increases a woman’s
chances of broken and more slowly healing bones as she ages, as well as the risk
of osteoporosis, a degenerative bone disease. While osteoporosis cannot be
reversed or cured once it develops, it can be prevented and slowed. Prevention
includes exercise (especially weight-bearing/resistance training); early life cycle
attention to diet, with particular attention to sufficient calcium intake through
food, not supplements; reduction in animal protein and in the amount of alco-
hol and nicotine ingested; and hormone therapy/hormone replacement ther-
apy (HT/HRT). HRT, a controversial treatment due to its possible links with
certain cancers, can be taken orally, as patches, gels, or vaginal inserts. Osteo-
porosis may be a culture-specific disease of middle-class industrialized women.
It is not reported as often in China, Japan, or in certain Latin American peas-
ant societies where diet and exercise may serve as preventative agents (Beyene,
1989; Ninghua et al., 2002). Interestingly, Japanese-American descendants of
immigrant women to the United States do experience more North American
menopausal symptoms, including osteoporosis and hot flashes (Lock, 1993).
Breast development, not breast size or firmness, is another estrogen-related
secondary sex characteristic. Breast development includes the growth of the
nipples, areola (the pigmented area surrounding the nipple), and the de-
velopment of the milk ducts within the breasts. Lifting weights to increase
upper body strength can strengthen the supporting pectoral muscles so
that breasts sag less. Breast tissue is highly fatty. Over the past three gen-
erations, our culture has emphasized basing female attractiveness on breast
size and shape. It is ironic that in a culture currently obsessed with female
thinness, fatty (i.e., large breasts) are viewed so positively. In contrast, most
nonindustrialized societies value women’s breasts as a life-sustaining source
of nourishment for the young rather than primarily as an erogenous zone
(see Figures 6.1).
Women’s and men’s bodies, not culturally manipulated through extreme di-
eting, use of steroids, or lifting weights, contrast markedly in relation to muscle
mass and fat ratios relative to overall body mass. This difference is primarily
attributed to the estrogen-testosterone hormone ratio. Women, overall, tend
to have less muscle mass and more body fat than do men. Not only do they
float in water more readily than men, but they tend to have more endurance
as well. This is exemplified in their roles as gatherers with kids in tow, and
their ability to go through labor and childbirth—the supreme mobilization
of prolonged energy expenditure. Women tend to be slower, lighter, have less
physical strength than men, and tend to carry body fat lower (i.e., on their
hips, buttocks, and thighs). Since fat is a metabolic insulator, it is one way of
keeping reproductive pelvic organs (uterus, fallopian tubes, and ovaries) both
warm and protected. It also means that women compared to men tend to be
less prone to coronary heart disease (CHD), which currently is correlated
with upper body fat, more often associated with men.
From an evolutionary perspective, the higher fat/body mass ratio in
women and its distribution pattern could be adaptive for a developing fetus
and neonate. The fat insulates and protects the fetus. Pregnancy, birth, and
breastfeeding require high energy expenditures. Given the reality of periodic
food shortages and famines, which have occurred throughout hominid evo-
lution, it is estimated that the fat reserves a woman carries could sustain her
and a fetus/neonate for about eighteen months (Ember and Ember, 1990). In
non-culturally induced famine situations, this would probably allow a group
sufficient time to locate new food resources without seriously jeopardizing
the survival of both a large number of their young and the females of repro-
ductive age.
Females also need a minimum of 17 percent body fat in order to reach pu-
berty and establish and maintain a regular menstrual cycle, including regular
ovulation. According to the Centers for Disease Control and Prevention
Figure 6.1 Range of female breasts from the adolescent period.

Source: Provided by www.007b.com.
(CDC), women who have less than 18.5 percent body fat are underfat/under-
weight (“Defining Overweight and Obesity,” 2005). This also means that in
many nonindustrialized societies, girls have greater muscle mass and aerobic
fitness due to their mobility patterns. Because they eat less dietary fat, they
may reach puberty later than girls do in industrialized societies where sed-
entism is more common and the diet is higher in fat and overall calories. In
a few African societies, for example, prepubescent girls undergo a period of
fattening which accomplishes several goals. It increases their body fat to the
point they achieve puberty and fattens them so they are culturally defined as
attractive and eligible for marriage and pregnancy. The common occurrence
in nonindustrialized societies of adolescent sterility may actually be a function
of insufficient body fat for puberty and regular menstrual cycles to occur. See
Chapter 11 for further discussion.
In the United States, current standards for a lean female are about 21 percent
body fat; the average is about 24 percent (“Defining Overweight and Obesity,”
2005). Given our current interest in female thinness, many younger women, in
particular, diet and exercise themselves into fashionable leanness and irregular
menstrual cycles. One clear sign of anorexia nervosa, a severe and dangerous
eating disorder that primarily is found in middle-class adolescent females, is
cessation of menstruation. Women athletes whose body fat is less than 17 per-
cent also can experience menstrual and ovulatory irregularities depending on
the quality of their diet. These irregularities are reversible upon increasing the
body fat ratio beyond 17 percent. Our present standards of female beauty in
essence would have women look like lean males with breasts, and reinforce a
cultural pattern of potentially serious eating disorders for a sizable number of
our population. It is also interesting that a female athlete’s price for competi-
tive leanness may be altered menstrual cycles. Similarly, extremely lean males
who have less than 6 percent body fat may have reduced production of sperm
(Wheeler et al., 1984).
These secondary sex characteristics can be culturally interpreted not only as
indicators of sexual adulthood, but also as visual sexual cues exemplified by fea-
tures such as breast development, appearance of pubic hair, or widening of the
hips. In contrast to males where spermatogenesis is hidden, menstruation is a
visible and clear marker that primary sex and reproductive characteristics have
been achieved. The development of the primary sex characteristics is related to
the H-P-G axis and release of estrogen and progesterone from the ovary.
Primary Sex Characteristics

Estrogen and progesterone overlap in their effects on the primary sex charac-
teristics, which include the growth and development of the external genitalia
and the internal reproductive structures. A female’s external genitalia are re-
ferred to as the vulva (see Figure 6.2).
The mons, mons pubis, or mons veneria is a fatty pad of tissue covering the
pubis. It is sensitive to sexual stimulation and is covered with the upper part of
the triangle of pubic hair. The labia majora, or outer lips, are homologous to
the scrotum. They are fatty pads of tissue covered with pubic hair. Sensitive to
sexual stimulation, they can engorge with blood during sexual arousal. They
extend from the bottom part of the mons to the base of the exterior vagina or
introitus. The labia minora, analogous and homologous to the foreskin and
shaft skin of the penis, are hairless, fatty pads of tissue that are surrounded
by the labia majora. They form the prepuce or clitoral hood at their top and
the base of the introitus at the bottom. Sensitive to sexual stimulation, they
vary in size, shape, and degree of pendulousness. In some societies they are
seen as symbols of beauty and erogenous zones. For example, the Mangaiians
Prepuce
Glans clitoris
Labia minora
Corpus cavernosum
Bulb of vestibule
Urethral opening
Labia majora
Vaginal opening
Opening of right
Bartholin’s glands
Anus
Bartholin’s glands
Vulva: External anterlor view Vulva: Internal anterlolateral view
Figure 6.2 Vulva: exter nal anterior and inter nal anteriolateral view.
Source: Illustration from Anatomy and Physiolog y Connexions website http://cnx.org/content/col11496/. June 19, 2013. Reproduced in Wikipedia. https://en.
wikipedia.org/wiki/Clitoris
have more words to describe the aesthetics of the vulva and clitoris than do
industrialized societies, where many of the terms carry negative connotations
(Marshall and Suggs, 1971).
In other societies such as in the Sudan, the labia minora are ritually surgi-
cally removed in order to preserve a woman’s modesty, virginity, and chastity.
Currently, this female genital surgical procedure known as excision is gener-
ating tremendous controversy. It and other forms of female genital surgery will
be discussed separately.
The clitoral hood or prepuce, formed by the juncture of the labia minora,
loosely covers the clitoris. The prepuce is analogous and homologous to the
foreskin, particularly where it covers the glans of the clitoris. Smegma also
collects under the clitoral hood as it does under the foreskin and functions as
a lubricant in both instances. The friction of the prepuce over the clitoris can
produce intense sexual stimulation.
The clitoris, composed of a glans, shaft, crura or legs, and urethral sponge,
is supported by a dense pelvic musculature and has more nerve endings in
its glans than does the glans of the penis. Despite its depiction in a number
of medical and physiology texts as a “small, pea-like structure, the clitoris is
actually about four to six inches in length, most of which is located inter-
nally” (Chalker, 2000). While homologous to the penis, it is not analogous to
it (Freud aside!). The only known function of the clitoris is sexual pleasure. It
is the only organ in the human body whose sole function is sexual pleasure.
This characteristic functionally distinguishes it from the penis which has four
functions: sexual pleasure, a transport mechanism for ejaculate, an organ of re-
production in penile-vaginal intercourse, and a transport mechanism for urine
(see Figures 6.3).
Figure 6.3 Clitoral hood and clitoris.

Source: Wikipedia. https://en.wikipedia.org/wiki/Clitoris, accessed March 8m 2021.
Long-standing, widespread, and ongoing controversies abound in
Euro-American societies concerning the function of the clitoris. Within the
twentieth century alone, there have been the Freudian clitoral versus vaginal
model; Masters and Johnson’s model with physiological centering of female
sexual response in clitoral stimulation; the Singer model of sexual response;
and the G-spot model of sexual response. See Chapter 12 for a more detailed
discussion of female sexual response. The clitoris is a source of cultural interest
and definition in nonindustrialized societies as well.
In both industrialized and nonindustrialized societies this interest has been
expressed at times in various forms of clitoral surgery, including circumcision
which removes the prepuce, and clitoridectomy, removal of the glans or shaft.
In the United States, these surgeries began in the mid-nineteenth century to
curb female masturbation and cure female insanity. The surgeries persisted into
the 1930s. In the nineteenth century, women’s sexual and reproductive struc-
tures were seen as the source of their behavior, affect, and attitudes. Female
sexual and reproductive surgery was performed on women who did not conform
to their culturally defined roles as good wives and mothers. Medical residents
learned these procedures on slave women, lower-class women, and émigrées, and
then performed them on middle-class women (Barker-Benfield, 1975; Ehrenre-
ich and English, 1978; Martin, 1987). A gynecologist performed a variation of
a clitoridectomy in the 1970s and 1980s by moving the clitoris closer to the in-
troitus in order to “ease” vaginal orgasms for some women in the United States.
The twenty-first-century parallel to this practice is women who have their

labia minora surgically sculpted to be “more symmetrical and less obvious.”
Cultural-psychological and physiological studies of female sexual response in

the United States consistently indicate that clitoral stimulation of some form
is a necessary and important aspect of female arousal and orgasmic ability
(Hite, 1976, 1987; Kinsey et al., 1953; Masters and Johnson, 1966, 1970, 1974).
The clitoris is a physiological center of sexuality for many women.
Between the clitoris and the introitus is the urinary meatus. This opening
is the end point of the urethra, which transports urine from the bladder to out-
side the body in both men and women. Urinary tract infections (UTIs) and
cystitis are two common problems that occur more frequently in women than
men. This is due to women’s shorter urethras and the kind of friction a woman
experiences during penile-vaginal intercourse (p-v), which more readily leads
to irritation of the female’s urinary meatus and urethra than the male’s.
The external vagina is below the urinary meatus. The introitus is the open-
ing to the vagina. It is surrounded by a ring of muscle known as the pubo-
coccygeus muscle, which helps the introitus to open and contract. These are
the same muscles surrounding the crura, or root of the penis. The introitus is
the final passageway for a fetus and menstrual blood. It is also the entry point
for penile-vaginal intercourse and for reproductive sex. The introitus as the
external part of the vagina takes on culturally defined physical, sexual, psycho-
logical, and reproductive connotations.
The prepuce, clitoris, and introitus are all subject to cultural curiosity, defini-
tion, and interpretation in both industrialized and nonindustrialized societies.
Industrialized societal interest has been discussed briefly. Nonindustrialized
culture has been introduced. Circumcision, clitoridectomy, and infibulation
are forms of genital surgery presently practiced in some nonindustrialized soci-
eties, most notably in Muslim sub-Saharan African groups. Infibulation entails
extensive genital surgery.
Infibulation can include circumcision; excision of the clitoral glans, shaft,
and labia minora; and closure of much of the introitus through excising and
sealing the labia majora. These procedures have received a great deal of atten-
tion recently by varied groups including the media, United Nations, World
Health Organization (WHO), and researchers. Introduced here, the prac-
tices which follow are also discussed in Chapter 11. These indigenous pro-
cedures have been affected by acculturation or culture contact. They are
sources of intense controversy concerning their sexual, reproductive, and psy-
chological effects on the women, their partners, and the kin groups involved
(Lightfoot-Klein, 1989, 1990; Ohm, 1980). Issues of ethnocentrism, cultural
relativism, and indigenous cultural integrity are involved. For example,
among the Gbaya, a horticultural group in central Africa, removal of the glans
clitoris in pubescent girls is a rite de passage (initiation ceremony), a symbolic
and real marker of her transition from girlhood to womanhood. The girls go
through this ritual together as part of a larger social group. Gbaya interpret the
clitoridectomy as making her less male and more female. She emerges from the
ritual as a recognized adult. Pubescent boys, circumcised at a younger age, un-
dergo a similar procedure in which their glans is nicked so they can participate
in their female peers’ ritual. Do we as members of industrialized societies have
a right or obligation to interfere with these practices? How well do we socialize
our adolescents into adulthood? What painful physical and psychological costs
do we extract from our young? Are people being mutilated physically, socially,
psychologically? Who makes this determination? These are extremely difficult,
emotionally charged behaviors within cultures, let alone between cultures.
Resolution of their controversial aspects will take a long time to achieve.
Another anatomical structure that generates much cultural interpretation
and concern is the hymen. The hymen is most likely a vestigial organ with
no currently known function. It is semi-permeable and partially or completely
covers the introitus in many women. The nature of the hymen is of particu-
lar concern in patrilineal (descent through the male line), bilateral (descent
through the male and female line), and patri-centered (male-centered) descent
groups where paternity must be known for offspring to have a legal, social,
economic, and political place in the society.
The condition of the hymen is used to define a female’s virginity and chas-
tity. Virginity, a physiological state, is attributed to someone regardless of gen-
der who has never had a penile-vaginal intercourse. Chastity is a socio-cultural
condition in which an individual, regardless of gender, lives by the cultur-
ally appropriate sexual code of behavior, affect, and attitude as defined by the
group. For example, a woman who is a “good wife and mother” by her culture’s
definitions and standards is no longer a virgin but can still be chaste. How? By
following her culture’s rules concerning such behaviors as appropriate dress;
speech (she “watches her language” in front of her children); or sexual behav-
ior (she responds to her husband’s advances but does not initiate sex).
While chastity and virginity ideally are gender free, their cultural inter-
pretation in bilateral and patrilineal descent groups usually results in a dou-
ble standard of sexual behavior. Promoting non-chastity and non-virginity for
males demonstrates their potential fertility and actual virility, both necessary
for reproductive success. In contrast, repressing female sexual behavior in
these patricentered societies except under strict culturally controlled situa-
tions such as strictly enforced monogamous marriage accomplishes two goals.
It achieves reproductive success since the woman does not have to be orgasmic
or ejaculatory in order to conceive and give birth. Second, controlling her sex-
ual behavior and severely limiting her sexual outlets and number of partners
helps to make certain the paternity of the child. He is probably her one and
only sexual partner. This double standard is culturally widespread and persists
in the United States. For example, surveys of US college students’ sexual be-
havior over the past twenty years indicate women still are subject to greater
disapproval than men for having multiple sexual partners, particularly when
emotional attachment does not exist (Crawford and Popp, 2003; Reiss, 1986;
Whelehan and Moynihan, 1984). In some Mediterranean societies, chastity
and virginity are affirmed on a bride’s wedding night when blood, either hers
or from a vial of sheep’s blood given to her as a gift by her female relatives,
appears on the sheet after her first intercourse. During the Middle Ages ius pra-
mae noctis or first night rite was a common ritual performed on brides on their
wedding night. They were “deflowered” by the owner of the fief in order to es-
tablish proprietary rights over the serfs—men, women, and children—as well
as the land (Bullough, 1976; Fernea, 1989). Currently, in some sub-Saharan
African societies, virginity tests and certificates for females (but not males!)
are issued as a means to reduce HIV infections.
Bartholin’s glands are located on each side of the base of the introitus.
These small glands generally are unnoticed unless they are infected, in which
case they can swell painfully. Bartholin’s glands secrete a clear fluid; their
function is unknown presently. Bartholin’s glands are homologous to Cowper’s
glands in the male (see Chapter 5).
The perineum is homologous in males and females and extends from the
base of the introitus to the anus. Soft, generally hairless, and sensitive to sex-
ual stimulation, the perineum stretches during vaginal childbirth to allow
the baby to pass through the introitus. As with many other aspects of female
sexual and reproductive anatomy, the perineum is subject to cultural scrutiny
and controversy. The ability of the perineum to stretch during childbirth is
culturally manipulated.
In most nonindustrialized societies women give birth semi-upright, which
relaxes and stretches the perineum. In addition, many societies further stretch
and soften the perineum through massage or the application of warm com-
presses or oils. These efforts reduce the chance of perineal tears during child-
birth (Arms, 1975; Boston Women’s Health Collective, 2005; Davis-Floyd,
2001; Janssen et al., 2002; Johanson, Newburn, and MacFarlane, 2002; “Mid-
wives and Modernization,” 1981).
In the United States, a common way of stretching the perineum during
childbirth is through an episiotomy, a surgical incision in the perineum. This
is believed to reduce the possibility of perineal tears, a high probability given
the dorsal lithotomy position (lying on one’s back) used in over 90 percent
of US births (Arms, 1975; Davis-Floyd, 1992, 2001; Masters, Johnson, and
Kolodny, 1982). Episiotomies are one of several current controversies in US
childbirth practices. These controversies will be dealt with in more depth in
Chapter 9.
Internal sexual and reproductive structures include the vagina, uterus, fal-
lopian tubes, and broad ligament. The internal vagina, a tubular, muscular
organ, extends from the introitus, back about four to five inches in a curved
manner, ending in a blind pouch or cul-de-sac known as the Pouch of Douglas.
As a structure, the walls of the vagina rest on one another. Androcentrically
(i.e., from a male perspective), the vagina is often described as a potential
space. It is a passageway for menstrual blood, sperm, and the birthing fetus. Its
expansion capacities are remarkable. From a state of collapsed walls to being
able to accommodate a penis or a full-term baby indicates a high degree of flex-
ibility. As a sexual structure, its orgasmic function is a source of cross-cultural
interest, definition, and discussion (e.g., the Kaama Sutra of Vatsayana in Freud,
1920a; Garrison, 1983; Gregersen, 1983; Hite, 1976, 1981, 1987; Kinsey et al.,
1953; Masters and Johnson, 1966). For many women in the United States, it is
both a psychological center of sexuality and a sex organ (see Berman, Berman,
and Bumiller, 2001; Hite, 1976, 1981, 1987). In addition to its sexual functions,
it is a reproductive structure.
The vagina is a sexual and reproductive structure with a pH of about 4.5–5;
making it slightly acidic. The acidity of the vagina and its natural flora keep
it clean and healthy. It is the cleanest orifice in the human body. Regular,
frequent douching is unnecessary and can upset the pH levels, irritating the
mucosa and leading to irritation and infections. Disruptions in the vagina’s pH
balance or flora can be caused by antibiotics, STDs (Sexually Transmitted Dis-
eases), stress, or illness. A healthy vaginal mucosa premenopausally is pinkish,
firm, springy, and moist. Vaginal lubrication or exudate, which occurs during
sexual arousal, passes directly through the vaginal mucosa (lining). Healthy
vaginal mucosa is maintained largely through estrogen, low stress, a balanced
diet, and general hygiene.
Since a healthy vagina is slightly acidic, there is a possibility of incompat-
ibility with a male sexual partner’s semen, which is basic. In some instances,
this may cause fertility problems. Also, popular fads to alter the pH of the
vagina to increase the chances of conceiving the desired sex are generally a
waste of time, money, and effort, as they may damage sperm or irritate the
vaginal mucosa.
The vaginal mucosa changes with menopause. The reduction in estrogen
production can result in drying and thinning of the mucosa which can lead
to painful intercourse. The irritated mucosa can be soothed through the use
of water-based lubricants such as K-Y Jelly, Probe, or Forplay, or through hor-
mone replacement therapy/hormone therapy (HRT/HT), either as a topical
ointment, or in pill or tablet form (Seaman and Seaman, 1977; Stewart and
Spencer, 2002; Stewart et al., 1979). However, data from the nationwide Wom-
en’s Health Initiative Study indicates that the risks of taking HRT may out-
weigh the benefits. There are alternative behaviors and herbal drugs that can
ease the symptoms of menopause that women may want to consider either
in addition to or instead of HRT (NIH, 2002). These include wearing layers
of clothing, reducing the amount of hot liquids and caffeine consumed, and
taking chasteberry or black cohosh to reduce the intensity and frequency of
hot flashes. Water-based lubricants can alleviate vaginal dryness and make
intercourse more comfortable.
Located on the anterior wall of the vagina, under the pubis and about one-
third of the way in from the introitus, is the location of the alleged “G-spot”
or Grafenberg spot. “Alleged” is used because the very existence of the
Grafenberg spot is challenged by some sexologists (e.g., Masters, Johnson, and
Kolodny, 1985). MRIs do not show the existence of a G-spot during missionary
position (man on top) p-v intercourse (Schultz et al., 1999).
Those researchers who accept the existence of a “G-spot” state that it is a
source of orgasmic potential and associate it with female ejaculatory ability
(e.g., Kiefer, 2005; Ladas, Whipple, and Perry, 1982). Under penile penetra-
tion with the woman on top, or with direct deep finger pressure, the “G-spot,”
an area of soft tissue, increases in size and produces a sense of sexual pleasure.
Continued stimulation may result in orgasm as well as the ejaculation of fluid
from Skene’s or the paraurethral glands that are located on each side of
the “G-spot.” The chemical composition of this fluid, sometimes referred to
androcentrically as female ejaculate, is debated (Ladas, Whipple, and Perry,
1982; Mahoney, 1983). Since some researchers believe this fluid is similar in
composition to prostatic fluid, skene’s gland can be referred to as the “female
prostate.” This fluid is deposited into the urethra and expelled from there
during “G-spot” orgasmic response. The expulsion of this fluid from the ure-
thra has led some women, their partners, some researchers, and physicians to
believe that these women experience urinary stress incontinence (USI) or
involuntary leakage of urine. Unless these individuals are into “water sports”
(playing with urine which in the age of AIDS may be a risky behavior), this
belief has created orgasmic problems for some of these women, distress for
some of their partners, and has led a few physicians to perform surgery on
these women for USI (Ladas, Whipple, and Perry, 1982). The intensity of
the controversy surrounding the entire “G-spot” phenomenon as opposed to
accepting it as a possible variation of sexual response is another indication
of our continued discomfort with sexuality in general and women’s sexuality
specifically.
The broad ligament is a band of connective tissue across the woman’s lower
abdomen that supports the uterus, fallopian tubes, and ovaries. As a support-
ive structure, it is one reason why women have fewer abdominal and pelvic
hernias than men.
The ovaries are homologues and analogues of the testes. Pearly gray and al-
mond shaped, they are located in the lower pelvis, slightly lower and adjacent
to the fallopian tubes. The ovaries are the female gonads, responsive to stimu-
lation by the pituitarian hormones FSH and LH. They are the primary sources
of estrogen and progesterone and are palpable under gentle stimulation during
a pelvic exam. As an introduction, the ovaries contain the eggs, or ova, in tiny
sacs called follicles. A woman is born with all the ova she will ever have. She
matures and releases about 400 eggs during her reproductive life cycle. Egg de-
velopment and number are in some ways a degenerative process in contrast to
spermatogenesis. A female is born with about half the eggs she had as a fetus.
Although several eggs start to mature with each menstrual cycle, usually only
one achieves maturity and is released. The other ripening eggs during that
cycle are reabsorbed by the ovary (Berek, Adashi, and Hillard, 1996).
The ovaries serve hormonal, reproductive, sexual, and cultural functions.
They produce the female gonadotropins, estrogen, and progesterone, and ma-
ture and release eggs in preparation for fertilization. By releasing estrogen and
progesterone they help maintain uterine tone and functioning, and maintain
a healthy vaginal mucosa, both of which play roles in reproductive and sexual
response. Ovaries are given cultural significance related to femininity, ma-
ternal behavior, and appropriate gender role behavior. In fact, oophrectomy,
removal of the ovaries or female castration, was commonly performed in the
United States during the nineteenth century to “cure” female insanity or to
enforce “gender appropriate behavior” (Barker-Benfield, 1975; Boston Women’s
Health Collective, 2005; Ehrenreich and English, 1978; Klee, 1988). This prac-
tice is another example of our culture’s consistently negative attitudes toward
female sexuality.
The fallopian tubes extend from the fundus of the uterus for about five to
seven inches to the ovaries. They do not cover the ovaries. Hollow, with hair-
like cilia projections along their inner walls, they are about the size of a broom
straw or thin strand of spaghetti. Homologous and analogous to the vas defer-
ens in males, they end as fibrillated or tendril-like organs. At ovulation, when
an egg is released by the ovary, the adjacent fibrillated ends of the fallopian
tube generally draw the egg into the tube. Fertilization usually occurs in the
distal or far end of the tube called the ampulla, where the tube curves. The
egg, regardless of whether it is fertilized, is moved down the tube by the cilia.
It takes the egg several days to reach the uterus. If fertilized, it may implant in
the corpus section of the uterus and begin to develop into an embryo, then a
fetus. If unfertilized, the egg passes through the uterine cavity.
The fallopian tubes are the normal site of fertilization; the uterus is the nor-
mal site of implantation. Occasionally, however, a fertilized egg embeds outside
the uterus. This is called an ectopic pregnancy. The most common site of an
ectopic pregnancy is a fallopian tube. An ectopic pregnancy is a life-threatening
medical situation. The embedded egg will grow in the tube until the tube
bursts. Initially mimicking a uterine pregnancy (e.g., cessation of menstruation,
possible breast tenderness, and nausea), an ectopic pregnancy can be diagnosed
by a careful and thorough pelvic exam, pregnancy tests, or an ultrasound. Early
diagnosis is important, as the tube will burst by the end of the first trimester.
Treatment currently entails either drugs, resectioning of the affected tube after
removal of the embedded embryo, or removal of the affected tube (Coste et al.,
2004; Kamwendo et al., 2000; Lipscomb, Stovell, and Ling, 2000).
Although fallopian tube transplants in humans have been done (Schenker
and Evron, 1983), as of yet, successful transplants of ectopic pregnancies to
a uterine environment are not possible. Ectopic pregnancies occur in about
2–5 percent of pregnancies. The incidence of ectopic pregnancies is related to
sexually transmitted infections such as gonorrhea and chlamydia, which scar
the fallopian tubes, and the growing occurrences of endometriosis and pelvic
inflammatory disease (PID) that can result from these infections (Coste et al.,
2004; “Current Trends Ectopic Pregnancy,” 1995; Kamwendo et al., 2000).
The uterus or womb is composed of several parts and performs both sexual and
reproductive functions. The uterus, a pear-shaped organ about the size of a large
thumb, is located in the central lower pelvic area. It extends into the vagina. The
uterus is a muscular organ that produces prostaglandins. Prostaglandins are hor-
mones which perform a number of functions including contraction of the uterus.
Prostaglandins may be involved in the uterine contractions that occur during
orgasm, those that occur during menstruation and cause menstrual cramps, and
as a partial cause of uterine contractions during labor. As one of the strongest
muscles in the human body, the uterus can be exercised and toned. Part of the
tone of the uterus is due to the release of hormones such as LTH, progesterone,
and prostaglandins. Uterine tone is also maintained through orgasms, during
which the uterus contracts (Answers.com, 2005; Sherfey, 1972). A healthy, toned
uterus allows not only for greater chance of retaining an implanted embryo, but
for its development and expulsion nine months later. Female orgasms then, not
only feel good, but may help to contribute to reproductive success.
Among the Sambia and some groups in sub-Saharan Africa, regular in-
tercourse with ejaculation and orgasm in the women is seen as helping
the development of the fetus. During the Renaissance, in Italy, people
believed that a child would be healthy, attractive, and intelligent if
both partners had an orgasm during conception. “Folklore” may have
more basis in science than is commonly believed in some situations
(Herdt, 2006).
The uterus is composed of several layers: the myometrium, parametrium, and
endometrium. The parts of the uterus to be discussed include the fundus, the
corpus, the cervix, the os, and the endometrium. The fundus is the rounded
top part of the uterus. As the uterus enlarges during pregnancy, the fundus can
be felt externally through the lower abdomen as it rises above the pelvic bone.
The corpus or body of the uterus is composed of several layers of which only
the endometrium will be discussed. The fallopian tubes enter the uterus at the
bottom of the fundus and beginning of the corpus. The corpus extends into
the vagina from its lower section, the cervix.
The cervix extends into the vagina and can be felt by deep insertion of the
fingers into the vagina, and can be seen by the use of a mirror and speculum. A
speculum is the instrument used during a pelvic exam to separate the walls of
the vagina. The cervix receives a lot of medical and lay attention. The cervix
is the site of the PAP smear (Papanicolaou smear). The PAP test is part of a
gynecological exam. Cells are gently scraped from the cervix and analyzed to
detect cervical normalcy and abnormalities, including cancer. Cervical cancer
is one of the more common cancers to affect women. Regular PAP smears every
one to three years help to ensure early detection and treatment (see Figure 6.4).
The cervix changes in color and texture depending on whether or not a
woman is pregnant. In non-pregnant women, the cervix is pinkish and carti-
laginous in texture, similar in texture to the tip of your nose. In response to
Figure 6.4 Female reproductive system: drawing of the internal sexual anatomy.
Source: GFDL Issue resolved in 2003. GNU Free Documentation License https://en.wikipedia.
org/wiki/Human_reproductive_system#/media/File:Female_reproductive_system_lateral.png
hormones released during pregnancy, the cervix softens to a state more similar
in texture to your lips, and changes color to a bluish-purplish hue. During sex-
ual arousal and orgasm, the uterus, including the cervix, responds in various
ways by retracting, contracting, and lowering into the vagina.
The cervix is the site of the os, an opening in the tip of the cervix generally
about the size of a thin pencil lead. It also changes in color and shape depending
on whether or not a woman is pregnant. A non-pregnant woman’s os is pinkish
and donut-hole shaped; a pregnant woman’s os is purplish or bluish and more like a
slit. This change in shape is irreversible after a woman has a child. These changes
in the cervix and os appear in the first trimester and are used as signs of pregnancy
during a prenatal pelvic exam. The os is the passageway for menses (menstrual
blood), the fetus, and sperm. During menstruation the os dilates slightly to allow
the shedding endometrium to pass through. The os is the structure that dilates or
opens during the first stage of labor to allow the baby to pass through.
Most of the month, the os is covered with a thickish, sticky substance called
cervical mucous. Cervical mucous is a protective barrier to keep foreign ob-
jects such as sperm, douches, contraceptive foams, or bacteria out of the sterile
uterine cavity. Just prior to and during ovulation, however, the cervical mu-
cous thins and becomes more permeable in order to allow the sperm entry to
the fallopian tubes where the egg may be fertilized. If the egg is fertilized and
implants in the endometrium, another mucoid substance, the cervical plug,
forms over the os as a protective seal for the fetus against foreign substances
entering the uterine cavity. The cervical plug usually is expelled during the
first stage of labor and is used as a sign that labor is imminent or has begun.
The endometrium is the innermost lining of the uterus. In response to
H-P-G axis hormones, estrogen builds up the endometrium, and progesterone
maintains it in the uterus. The endometrium serves as the anchor for the em-
bryo and fetus. The endometrium is a thick, cushiony layer of blood, tissue,
and mucous that accumulates each month in preparation for a fertilized egg.
The fertilized egg implants in the endometrium where it remains attached
for nine months by the placenta as it develops into an embryo and fetus. The
endometrium is shed as the menses or menstrual blood if fertilization and im-
plantation do not occur.
There is a clinical condition called endometriosis which is primarily found
among middle-class, college-educated, career women in the United States who
are in their late twenties and thirties. Many of them are nulliparous (they
have never borne a child). Endometriosis involves patches of endometrial
tissue found on the ovaries, external uterus, or other pelvic and abdominal
organs, and in the fallopian tubes. Endometriosis in the fallopian tubes can
cause tubal blockage and scarring, interfering with conception. Although the
exact cause of endometriosis is unknown, it is theorized that it may be due to
a variety of factors including prenatal disposition, hormone fluctuations, and
delayed pregnancy among some career women (Berek, Adashi, and Hillard,
1996; Stewart et al., 1979).
Symptoms of endometriosis include fertility and menstrual problems, pain
during both intercourse, known as dyspareunia, well as menstruation, known
as dysmenorrhea. Definitive diagnosis of endometriosis is through laparoscopy,
a surgical procedure that involves an incision in the abdomen where organs are
viewed through a lighted tube or laparoscope. Treatment can be hormonal or
surgical depending on the severity of the situation. In a number of cases fertility
may be restored (Berek, Adashi, and Hillard, 1996; Wade and Cirese, 1991).
The uterus, composed of several structures, is a marvelous organ. Its capac-
ity to change in size and function, depending on pregnancy, is phenomenal.
As a reproductive and sexual organ, it is imbued with a range of cultural con-
notations and definitions. For example, the sexual function of the uterus is
only recently being accepted and understood, making its already controversial
ritual removal (hysterectomy) post-menopausally in the United States an even
more debatable issue (Berman, Berman, and Bumiller, 2001; Boston Women’s
Health Collective, 2005; Klee, 1988). In general, in industrialized societies for
the past several hundred years, women’s mental health has been defined as a
function of her reproductive organs (Barker-Benfield, 1975; Klee, 1988). Freud
used a psychiatric classification known as hysteria from the Greek word for
womb, another term for the uterus. According to Freud, hysteria is primarily
an affliction of women, characterized by over-emotionality, denial, and depres-
sion (Freud, 1920a, b).
In both industrialized and nonindustrialized societies the function of the
uterus and ovaries are subject to cultural scrutiny. For example, in the Tiwi
society, an Australian foraging group, the essence of sexuality is female. Female
totems, religious, and animistic guardian spirits, which are inanimate sym-
bolic structures that are given lifelike characteristics, play a role in concep-
tion. Although the Tiwi realize that heterosexual contact and penile-vaginal
intercourse is necessary for conception, they need to explain why only certain
incidences of p-v intercourse results in conception. Their causal explanation
for heterosexual contact, which results in conception, is that a female totem
breathes life into the woman’s body. Part of Tiwi contraception then includes
appeasement of the female totems to avoid pregnancy (Goodall, 1971). Cultural
concern over this aspect of human behavior is matched by the degree of con-
cern human groups have with another bio-behavioral phenomenon, menstrua-
tion. Key concepts related to menstruation (the shedding of the endometrium)
are menarche, a girl’s first menstruation or period, and the menstrual cycle.
Menstrual Cycle
The menstrual cycle, a primary sex characteristic, has both sexual and re-
productive functions and is reproductively analogous to spermatogenesis dis-
cussed in Chapter 5. Both the menstrual cycle and spermatogenesis produce
the gametes (the egg or ovum) and sperm, respectively, which are necessary
for conception to occur. The menstrual cycle and spermatogenesis function
in response to the H-P-G axis. Other similarities include the involvement of
homologous structures such as the ovaries and testes, the fallopian tubes and
vas deferens. The menstrual cycle and spermatogenesis are physiological pro-
cesses culturally defined as signals of sexual and reproductive adulthood.
These are also sharp contrasts between the menstrual cycle and sper-
matogenesis. The menstrual cycle is just that, cyclic, roughly taking a lunar,
twenty-eight-day month, to follow through a round of H-P-G axis hormone re-
lease. The menstrual cycle is rhythmic as opposed to the tonicity of spermato-
genesis and male H-P-G axis functioning. The ovaries do not produce eggs as
the testes produce sperm; rather, several immature eggs start developing each
month in their follicles or sacs in the ovaries. Generally, only one egg reaches
maturity and is released at one point in the cycle, ovulation, as opposed to the
continuous, numerous—several-million-daily—production of sperm. The men-
strual cycle is highly visible in the menstrual phase when the endometrium is
shed through the os and out of the body vaginally. In contrast, spermatogenesis
is unmarked. There are no clear primary markers of this process other than the
irregularity of nocturnal emissions (i.e., wet dreams). Indicators of spermato-
genesis often are culturally defined through secondary sex characteristics such
as beard growth, voice changes, the growth spurt in height and limb length, or
through the imposition of initiation ceremonies or rites de passage, rituals that
socially take a person from one stage in the life cycle to another.
Another contrast between the menstrual cycle and spermatogenesis is the
arbitrary, finite nature of the menstrual cycle. Menstruation begins at puberty,
occurs roughly once a month for an average of four to seven days, and ends at
menopause. It is bleeding without injury, illness, or provocation. In contrast,
spermatogenesis is invisible. Sperm do not appear in other situations such as
illness or injury as blood may, and spermatogenesis is continuous from puberty
to death. The attributes of the menstrual cycle allow for a range of cultural
interpretation and action.
The discussion of the physiology of the menstrual cycle is adapted from
Speroff, Glass, and Kase (1978). The menstrual cycle is discussed in four
phases: follicular, ovulation, luteal, and menstrual or menstruation. Born with
all the eggs she’ll ever have, about 700,000, a woman will mature and release
a range of 200–400 eggs during her reproductive life cycle, barring illness,
injury, pregnancy, or surgery on her reproductive organs (Berek, Adashi, and
Hillard, 1996). Based on a lunar, twenty-eight-day calendar cycle, she will ma-
ture and release about thirteen eggs a year. These are averages for healthy
industrialized women. In reality, there can be considerable variation relative to
the length and regularity of the cycle and egg release, depending on variables
such as nutrition, amount of body fat, stress, illness, or pregnancy.
The regular, relatively uninterrupted menstrual cycles that many twenty-

first-century, middle-class, US women experience is probably a recent,
evolutionary anomaly. They are a function of bottle feeding, frequent
use of external, chemical, or barrier contraceptives, and fewer pregnan-

cies. The female hominid pattern, until recently, probably was one of
fewer regular menstrual cycles, since much of a woman’s life was spent
lactating for several years, interspersed with pregnancies (Beyene, 1989).
The follicular phase is the longest and most irregular of the four phases of the
menstrual cycle. Its length determines the overall length of the cycle and the
regularity from one cycle to the next. The follicular phase ranges between
eleven and sixteen days in length. Egg maturation occurs during the follicular
phase. Based on hypothalamic release of GnRH, the pituitary releases FSH
stimulating multiple egg maturation in the follicles of the ovary. About mid-
point in the follicular phase, FSH starts to falter which induces the release of
ovarian estrogen, specifically estradiol. Estradiol helps to stabilize the FSH
level and induces the release of LH. At this point, the end of the follicular
phase is approaching and LH performs several functions. It stops multiple egg
maturation, and helps to release the most mature egg from the follicle, which
is also aided by the release of androgens, specifically androstriol. During this
time estrogen regulates the levels of FSH and LH, maintaining a delicate bal-
ance between them since a surge of FSH would stimulate egg maturation again
and a drop in LH could impede the most mature egg’s release from the ovary.
For this reason, estrogen or estradiol is called the key regulating hormone in
the menstrual cycle. At the end of the follicular phase, the egg is ready to be
released, FSH is stabilized, and LH and estrogen levels are high (see Figure 6.5).
Data are inconsistent as to whether or not women experience an increased
interest in genital, heterosexual contact at ovulation. From reports some
women are “horniest” at ovulation, others are just prior to or during their
periods, others are throughout their cycle, and some not at all (Hite, 1976;
Masters and Johnson, 1966; Masters, Johnson, and Kolodny, 1985). While bi-
ologically it would “make sense” to be most interested in sex during ovulation
(consistently assumed to be p-v intercourse in much of the literature), human
sexuality is a complicated interaction of biology and learned behavior, includ-
ing perception and emotions. Human sexual behavior is culturally filtered and
expressed, which can explain the variation in research findings.
Ovulation is the briefest phase of the cycle. It is the release of the egg from
the follicle into the lower pelvis where it is generally drawn into its correspond-
ing fallopian tube. Ovulation occurs at mid-cycle. Generally a woman ovulates
once a month, but there can be variations due to stress, intense orgasms, or
irregular follicular and ovulatory patterns (Speroff et al., 1978). Thus, since a
woman can, though rarely does, ovulate more than once a month, it is untrue
that she cannot get pregnant during her period—that she’s totally “safe” then
as some US folk beliefs assert. In addition, some women’s cycles are sufficiently
irregular such that ovulation may occur during menstruation. A woman may
be aware of ovulation through a cramping or pinching sensation in her lower
abdomen from the ovary which just released its egg. This sensation is similar
A Human Reproductive Menstrual Cycle

Ovulation
LH
FSH
Estrogen
Progesterone
Day 1-4 14 21 28
B Rat Reproductive Menstrual Cycle
LH
FSH
Progesterone
Estradiol
Day 1: Day 4:
Day 2: Diestrus Day 3: Proestrus
Day Metestrus Estrus
Figure 6.5 Menstrual cycle diagrammatically.

Source: Adapted from Human Reproductive Cycle in Comparison with a Rat. Emanuel, Mary
Ann, Frederick Wezeman, and Nicholas V. Emanuel. “Alcohol’s effects on Female Reproductive
Function.” NIH.
to a stitch in one’s side after running. The cramping is called mittelschmerz.

It occurs as the egg bursts through the surface of the ovary; a small amount of
ovarian bleeding, which is absorbed by the body, may occur at that time as well.
The luteal phase is the third phase of the menstrual cycle. A lot of activity
can potentially occur at this time. A woman with late luteal phase disorder
(LLPD)/premenstrual syndrome (PMS) experiences it during the luteal phase.
During the luteal phase the egg is either fertilized or not. Each case will be
presented. The follicle that just released the egg is now called the corpus lu-
teum, which is Latin for “yellow body.” Upon stimulation by pituitarian LH,
the corpus luteum secretes progesterone. Progesterone maintains the endo-
metrium which was built up by estrogen in the uterine cavity. Progesterone is
released throughout this phase until it receives a signal from the decomposing
egg that fertilization has not occurred. LH levels are also elevated to stimulate
progesterone release until a “no fertilization” message occurs. If the egg is not
fertilized, it starts to break down. In turn, LH levels drop, which triggers a drop
in progesterone levels. At a certain point, the progesterone level is sufficiently
low that the uterine lining (i.e., the endometrium) cannot be maintained. It is
then shed as the menses. Concurrently there are drops in FSH and estrogen.
When estrogen and FSH are sufficiently low, the hypothalamus is triggered,
releases GnRH, and the hormonal release pattern begins again.
If fertilization occurs in the luteal phase, another set of hormonal patterns
occur. Estrogen and progesterone levels, maintained by FSH and LH, remain
elevated to keep the endometrium in place. The fertilized egg begins producing
its own hormones from the developing placenta, which at this stage is called
the chorion. The chorion produces human chorionic gonadotropin, HCG,
or “the pregnancy hormone.” HCG is called the pregnancy hormone because
it is the substance detected by standard at-home and clinical pregnancy tests.
HCG is produced until about the tenth to twelfth weeks of gestation, at which
time the placental steroids, another group of hormones, function to keep the
placenta attached to the endometrium. Up to this point of embryonic devel-
opment, HCG keeps the developing placenta attached to the endometrium.
Excess levels of HCG are secreted in the mother’s urine, with the highest levels
of HCG secreted early in the morning. Thus, a woman uses a urine specimen
for the pregnancy test.
The fourth phase of the menstrual cycle is menstruation or menses. On
average, menstruation is the four to seven days when the endometrium is shed.
Menses is composed of blood, tissue, and mucous. Menstrual blood amounts
to about one-half cup of liquid, most of which is expelled in the first forty-eight
hours of the woman’s period. The entire menstrual cycle, as well as menstrua-
tion specifically, generates widespread cultural interest and reaction.
Negative attitudes and beliefs about menstruation and women’s sexuality
are common in horticultural societies that are polygynous (i.e., allow more
than one wife); patrilineal (descent is through the male line); engage in en-
demic or ongoing warfare; and that have a high degree of segregation be-
tween the sexes. Men and women in these societies do not often interact and,
therefore, do not know each other well. As adults, their marriages frequently
occur as political strategies to settle disputes or form alliances against warring
groups. In groups such as the Yanamamo and Mae Enga, men fight, bleed, and
die for women who bleed spontaneously without apparent injury. In these so-
cieties, men must be careful of women’s sexual behavior or the lineage will be
damaged. These factors probably contribute to negative beliefs about menstru-
ating women. In addition, in many of these societies women control the food
supply and men are dependent upon them for food. The sum effect of these
intense behaviors can result in strong antifemale ideology by men concern-
ing women’s sexual and reproductive functions (Buckley and Gottlieb, 1988;
Herdt, 1981, 1987, 2006).
In many of these societies, women are further segregated from their peers
and men during menstruation by staying in a menstrual hut. Menstrual huts
are frequently described in the anthropological literature as the sine qua non
of female oppression and degradation. However, while in the menstrual hut,
women spend time with other menstruating women, eat special (i.e., restricted)
foods, and do not have to assume routine cooking, childcare, food prepara-
tion, and other work responsibilities. Are menstrual huts oppression, a break
from hard work, or an opportunity for women from different areas to socialize?
Menstrual taboos are by no means restricted to nonindustrialized societies.
They are alive and functioning currently in industrialized societies, impacting
women at work and at home (Olesen and Woods, 1986).
As stated at the beginning of this section, menstruation is a bio-behavioral
phenomenon. Three specific examples of this include menstrual cramps,
menstrual synchrony, and late luteal phase disorder (LLPD), more commonly
known as premenstrual syndrome (PMS) and more specifically as LLPD/PMS.
Data for these phenomena largely are derived from industrialized cultures.
Prostaglandins, released by the uterus, play a physiological role in menstrual
cramps. Prostaglandins cause uterine contractions. Depending on the amount
of prostaglandins released, and the strength, intensity, and frequency of the
contractions, these contractions may be experienced as cramps. The woman’s
pain threshold and tolerance for this kind of sensation, in addition to her
learned attitudes and behavior toward her body, menstruation, and expres-
sions of pain, all contribute to the phenomenon of cramps. Exercise, orgasms,
and aspirin are all reported to be helpful in alleviating cramps.1 Cramps are
no more “all in your head” than they are a complete function of “raging hor-
mones,” both of which are popularly held beliefs in the United States.
Menstrual synchrony is both documented and controversial. Menstrual
synchrony is the eventual synchronization of menstrual cycles among women
who live near one another and are in close contact. It may be an evolution-
arily recent phenomenon with a number of determining variables that are
not well understood (Mealey, 2004; Weller and Weller, 1998). Physiologically,
menstrual synchrony may be a function of pheromone release. Pheromones,
which were discussed earlier in this text, are sexual scent signals or olfactory
cues. It is believed that pheromones may be the hormonal basis in evening
out and regulating women’s periods. Since menstrual synchrony only occurs
among women who are both emotionally bonded and who are in frequent con-
tact with each other (e.g., they live together and spend time with each other),
this would allow for them to key into each other’s pheromone patterns. The
pattern is broken if either the emotional tie or contact is disrupted (McClin-
tock, 1971). Menstrual synchrony could have potential for reproductive success
if women have regular heterosexual genital sex partners. Regular ovulation
and menstrual cycles coupled with continuous sexual receptivity among these
women would increase the chances for conception. There is some evidence
that women who have regular p-v sex with their partners have shorter and
more regular menstrual cycles (Jarrett, 1984). How this works in polygynous
societies would be an interesting study.
Late luteal phase disorder (LLPD) or premenstrual syndrome (PMS), the
popular name for this phenomenon, currently is a controversial medical, so-
cial, and legal phenomenon in the United States and other industrialized cul-
tures (Buckley and Gottlieb, 1988; Martin, 1987). Some physicians deny its
existence (Masters, Johnson, and Kolodny, 1985), and others debate what it is.
The American Psychiatric Association includes LLPD/PMS under the diagno-
sis of late luteal phase disorder (LLPD) in its 4th edition of the Diagnostic and
Statistical Manual (DSM IV) (Berek, Adashi, and Hillard, 1996; Hamilton and
Gallent, 1990; Lips, 1993: 217). There are clinics and physicians in the United
States and other industrialized countries such as Canada and Great Britain
that address LLPD/PMS. LLPD/PMS is a collection of symptoms that range
in type, frequency, duration, and intensity. These symptoms occur during the
luteal phase of the menstrual cycle and disappear when menstruation begins.
LLPD/PMS may have a cumulative progression in its intensity, but it reportedly
primarily affects women in their twenties and thirties. The cause continues to
be investigated and debated. One explanation is that LLPD/PMS is caused by
fluctuating progesterone levels during this phase (Martin, 1987). It is estimated
that the vast majority of women (numbers vary widely) experience at least the
milder forms of LLPD/PMS at some point during their reproductive life cycles.
Symptoms range from mild to extreme. Milder LLPD/PMS includes headaches,
irritability, water retention resulting in clothes or jewelry not fitting well, a
feeling of lower body heaviness, lethargy, food cravings, particularly for salt and
chocolate,2 and weight gain that can range from 2 to 15 pounds that is lost after
menstruation. More severe symptoms tend to include emotional and behavioral
ones: mood swings, depression, increase of drug intake—particularly alcohol—
as well as nausea and migraines. In its extreme form, women state they experi-
ence uncontrollable fits of rage, violence, and depression, which may be acted
out toward oneself or others in the form of suicide attempts, child abuse, and
physical assault toward men they know (Martin, 1987; Tavris, 1992). These be-
haviors have legal and social consequences, which will be discussed later.
Although LLPD/PMS clearly may be culture specific, it may also be

further categorized as a folk illness in those industrialized cultures that
report it. The controversy within the medical profession in these cul-
tures concerns whether LLPD/PMS is an actual clinical entity or a vague
collection of symptoms. Aside from this debate is the folk perception of
LLPD/PMS. For example, a client of Patricia Whelehan’s labeled every
mood change she experienced as LLPD/PMS, regardless of when in her
cycle these mood changes occurred. Increasingly on the college campus
where one author teaches, many of the reasons given for “pigging out,”
being grouchy, or not working are attributed to LLPD/PMS by both men
and women, regardless of the accuracy of the label.
Treatments for LLPD/PMS include lifestyle modifications and hormone ther-

apy if necessary. A woman who believes she has LLPD/PMS needs to chart her
symptoms over a period of several months to note whether a pattern emerges,
and to try to control other factors such as stress at work or home. If a correla-
tion appears between the symptoms and the luteal phase, and these symptoms
do not appear at other times, a diagnosis of LLPD/PMS may be made.
Lifestyle modifications refer to nutrition, sleep, exercise, use of drugs, and
reduction in stress. Interestingly, the lifestyle modifications currently rec-
ommended as “healthy living” simulate those of our hominid gathering and
hunting behavior. These include a reduction in salt, saturated fat, refined
sugar, caffeine, alcohol, red meats, and an increase in the consumption of
complex carbohydrates, lean fish and poultry, grains, fruits, and vegetables.
Sufficient sleep and aerobic exercise are encouraged as well as the reduction of
the use of recreational drugs. Stress reduction techniques include biofeedback,
meditation, and guided imagery; anything that relaxes from within.
The extreme behaviors attributed to LLPD/PMS elicit legal and social re-
sponses. These behaviors include suicide attempts, child abuse, and murder.
Over the past fifteen years, some women accused of child abuse and murder
of men they knew have entered a plea of LLPD/PMS to courts in the United
States, Canada, and Great Britain. This plea has been accepted, and in some
cases, tried. In one case in Great Britain, the woman was acquitted on the
grounds of LLPD/PMS. Culturally, this evokes a strong response from men,
women, feminists, and non-feminists in support of both sides of LLPD/PMS
controversy. One set of arguments supports the reality of LLPD/PMS as a cause
of violent behavior and wants judgment and treatments given with LLPD/PMS
as a consideration. Another set of arguments believes the use of LLPD/PMS
in legal cases supports the view of women as irrational beings, subject to rag-
ing hormones that control their behavior, and who are not hormonally fit or
responsible beings. This side also believes that while intense depression and
anger may be caused by LLPD/PMS, there are outlets for these feelings other
than physical aggression toward oneself or others. By contrast, it is interesting
that testosterone is not a defense entered by men for acts of violence, not even
by the men Silber studied (see Chapter 5).
Rather than a clinical entity, LLPD/PMS may be a cultural construct that
allows women to “rage” once a month. Our culture historically sees women
as creatures of their hormones and denies them a legitimate way to express
their anger or frustration. LLPD/PMS may be a culture-specific “illness” that
permits women to show anger, frustration, or other culturally labeled negative
emotions. LLPD/PMS also reinforces the belief that women are victims of their
physiology, specifically their hormones (Tavris, 1992). It is linguistically and
culturally interesting that in the United States, LLPD/PMS is considered a
psychiatric disorder, not a medical or gynecologic problem (Berek, Adashi, and
Hillard, 1996). Is LLPD/PMS another cultural double standard, a newly found
physiological-behavioral phenomenon that we do not fully understand, or an
interaction of the two (Martin, 1987)?
In the past two chapters, male and female adult sexual and reproductive
anatomy and physiology have been presented. Their similarities are notable:
they share a common hormonal system and functioning that varies by de-
gree, amount, and patterning. Many of the structures are both homologous
and analogous with each other. These similarities will be reinforced in the
chapter on embryology and sexual differentiation in utero. In essence, on a
biochemical basis, men and women are more similar than they are different.
Much of how and what we define, label, and respond to as sexual, male
(masculine), or female (feminine) is probably as much a function of cultural
patterning as it is biology (Rogers, 2001). Culturally, we learn to attribute
positive and negative connotations to our bodies, behaviors, thoughts, and
feelings relative to sexuality. As bio-cultural beings we are sexual creatures. To
summarize this section, anatomy and physiology reflect:
• A species-wide bio-chemical commonality.

• A shared hormonal system as males and females.
• A number of structures that are analogous and homologous between
males and females.
• The link between our sexual behavior and a biological foundation.
• The interaction of biology and learned behavior in the expression of our
sexuality.
• Cultural meanings that are given to the biological basis of our sexuality.
Reproductive Technology
Reproductive technology, developed and in use since the mid-1970s, has had an
impact on our physical evolution as hominids. Currently, artificial insemination
by husband (AI-H) or donor (AI-D), in vitro fertilization (IVF), chromosomal
filtration for gender selection, embryo transplants, amniocentesis, and
chorionic villi sampling (CVS) are all available as alternative means of direct
heterosexual contact for reproduction.
Sperm banks for AI-D and AI-H are found in most major cities in the United
States. Over 1,000,000 artificial inseminations are performed each year. A gen-
eration of artificially inseminated babies has reached adulthood, some of whom
are trying to locate their biological fathers. Minimally, artificial insemination
means that men are no longer directly needed for impregnation, only their
healthy ejaculate is. AI-D is used by some lesbians who want to be both bio-
logical and sociological mothers without having p-v intercourse. A very simple
process is involved. All one needs is a fresh, healthy ejaculate sample, a syringe,
and an ovulating female.3 What are the potential consequences of AI-D and
AI-H for partnering, parenting, and for men? This is not a balanced situation.
Men still need women to carry the fetus and to give birth. Surrogate mothers
are not as accepted as are sperm banks and artificial insemination, although
increasingly, women are egg donors for infertile couples (see Chapter 7).
In vitro fertilization, “test tube babies,” is now rather common in industrial-
ized societies for couples for whom the woman has irreparably damaged fallo-
pian tubes (Nyboe, Gianaroli, and Nygren, 2004; Reynolds et al., 2003; Wright
et al., 2003). This procedure involves surgically extracting a mature egg from
the woman’s ovary, combining it with a fresh ejaculate sample from her hus-
band, and then implanting the conceptus (the fertilized egg) into her uterus.
Available since 1978, thousands of babies have been conceived and born by
this method, and are apparently physically and developmentally healthy. As
of 2002, the national average success rate for a live birth in the United States
is 40.7 percent. The procedure is expensive—several thousand dollars per at-
tempt (Andersen, Nyboe, and Nygren, 2004).
Chromosomal filtration of X and Y chromosomes to preselect a female or
male fetus is gaining in success and popularity. Developed in the late 1970s to
early 1980s by a reproductive embryologist in San Diego, this method report-
edly has an 85 percent success rate for Y chromosome filtration. From a spun
ejaculate sample, the lighter Y chromosomes filter to the top and the heavier
X chromosomes settle to the bottom of the tube. Chromosomes and semen for
the preferred sex are filtrated out and artificially inseminated into the woman.
Given that there persists in our own and other societies a widespread cultural
preference for sons, what are the implications of this procedure for future gen-
erations? What will happen with the “natural” gender ratio balance, if there
ever was one, which was relatively untampered with except by cultural ma-
nipulations such as female infanticide (Benagiano and Bianchi, 1999; Mal-
pani, 2002; “Towards Ending Violence against Women in South Asia,” 2004)?
We know that in both India and China currently, the preference for male
children has changed the gender ratio balance sufficiently to be reflected in
the adult population, affecting the number of women available as potential
spouses (Malpani, 2002; “Towards Ending Violence Against Women in South
Asia,” 2004).
Embryo transplants from one uterus to another are also being done. In
this situation a woman is artificially inseminated with another woman’s part-
ner’s ejaculate. The man’s wife usually has blocked fallopian tubes or prob-
lems with implantation. After fertilization occurs in the “donor” woman, the
conceptus or fertilized egg is carefully evacuated from her uterus after several
days and implanted in the wife’s uterus. In one case, the receiving parents
were killed in a plane crash and the state of the floating embryo was of legal
and social concern. In 1989, there was a court case in the United States in
which a divorcing couple contested ownership of their fertilized eggs. The
court decided in favor of the wife. She could have them implanted. Ques-
tions of paternity and future child support remain unanswered at this time.
We do not have legal, social, cross-cultural, or evolutionary models or prec-
edents that easily incorporate these phenomena into our sexual and repro-
ductive behavior and belief systems. These technological options force us to
rethink our attitudes about life, abortion, parenting, and “normalcy.” The use
of unused embryos for stem cell and other medical research comprises one of
the current ethical debates in assisted reproductive technology (ART) (see
Chapter 7).
Amniocentesis and chorionic villi sampling, CVS, detect chromosomal
normalcy, abnormalities, and gender in embryos and fetuses. By either with-
drawing amniotic fluid from the amnion during the end of the first trimester
(amniocentesis), or sampling chorionic tissue early in the first trimester (CVS),
much chromosomal data can be obtained and used to make a decision about
whether to continue or terminate a pregnancy. In either situation there is a
small chance of spontaneous abortion (miscarriage). In the case of amniocen-
tesis, a second trimester abortion would be performed, while with CVS, a first
trimester abortion, if selected, would terminate the pregnancy.
Fetal reduction is one of the more recent reproductive choices. It is in-
tended for use in a large multiple fetus pregnancy or where a twin or triplet
is seriously chromosomally or developmentally impaired. Fetal reduction is
highly controversial. Fetal reduction involves the induced abortion of the fe-
tus which has serious problems to help increase the chances of survival of the
other fetuses (Berek, Adashi, and Hillard, 1996; Kelly, 1990). The impact of
these technologies could change our reproductive practices and future. There
are clear implications for altered sex ratio balances, the number of adult men
needed in a population, concepts of sexuality and sexual relations, definitions
of gender and gender roles, as well as of parenting and families. These are not
Orwellian (1950) or Brave New World (Huxley, 1946) fantasies, but realities of
early twenty-first-century life. Sexual and reproductive choices and decision
making now are qualitatively different than in previous generations or in other
cultures including our own.
Summary
1 Female sexual and reproductive anatomy and physiology are an expression
of the CC + (H-P-G axis) formula.
2 Female hormonal functioning is generally described as cyclic, in contrast
to the male’s depiction as tonic.
3 The menstrual cycle is a function of a negative feedback interaction of the
H-P-G axis.
4 Many of the primary and secondary female sex characteristics discussed
are analogues and/or homologues of the male’s.
5 Differences in male and female body fat and muscle mass are culturally inter-
preted. Female primary and secondary sex characteristics are often dramati-
cally responded to culturally. Much cultural interest is shown toward female
sexual and reproductive functioning. This can include controversial genital
surgery such as circumcision, clitoridectomy, hysterectomy, and infibulation.
6 There are several models developed in industrialized societies to explain
the variety of female sexual response.
7 Various diseases and cultural management of female sexual and reproduc-
tive structures affect a woman’s fertility.
8 The menstrual cycle is a bio-behavioral phenomenon.
9 The menstrual cycle is culturally regulated and associated with taboos in
many societies, including the United States.
10 Menstrual synchrony, menstrual cramps, and premenstrual syndrome
(PMS) may be culture-specific, industrialized phenomena.
11 Anatomically, physiologically, and hormonally, men and women are much
more similar than they are different.
12 Numerous technologies such as AI-D and AI-H, in vitro fertilization,
and chromosomal filtration developed in industrialized societies over the
past fifteen to twenty years have the potential to radically change human
reproduction.
1 If virginity is defined as not having p-v intercourse, does that mean that
self-identified, behaviorally consistent gays and lesbians are always virgins
since they do not engage in this behavior?
2 Why do societies manipulate and pay more and different kinds of atten-
tion to female reproductive and sexual structures than they do male?
3 What kinds of immediate (proximal) and long-term (distal) evolutionary
changes could occur from ART?
Suggested Resources
Books
Boston Women’s Health Collective. 2005. Our Bodies, Ourselves: A New Edition for a
New Era. New York: Touchstone Publishers, Ltd.
Chalker, Rebecca. 2000. The Clitoral Truth: The Secret World at Your Fingertips. New
York: Seven Stories Press.
Diamant, Anita. 1997. The Red Tent. New York: St. Martin’s Press. Federation of Fem-
inist Women’s Health Centers. 1995.
Website
Museum of Menstruation. http://www.mum.org/.
7 Fertility, Conception, and
Sexual Differentiation
Chapter Overview
1 Defines fertility, sterility, infertility, and conception.
2 Delineates criteria for male and female fertility and infertility, and
discusses the causes of infertility in the United States.
3 Discusses cross-cultural and US reactions to fertility and infertility.
4 Discusses biological, cultural, and technological aspects of conception.
5 Defines genetic, gonadal or hormonal, and phenotypic sex, gender iden-
tity, and gender role.
6 Discusses the sexual differentiation process in utero.
7 Discusses intersexed persons including those with Turner’s Syndrome,
Klinefelter’s Syndrome, and XYY Syndrome.
Fertility and infertility, conception, and the sexual differentiation of the

embryo are the major topics covered in this chapter. As part of the discussion
of sexual differentiation, three of the more common, random chromosomal
errors are discussed.
Fertility and Infertility

Physiologically, fertility holds a different meaning for males and females. For
males, it is the ability to impregnate a female with one’s own sperm. For fe-
males, it is the ability to be impregnated; that is, to ovulate, have patent or
open, unblocked fallopian tubes, and carry a fetus to term. Currently in the
United States, fertility is generally assumed unless proven otherwise.
People also are assumed to be the most fertile in their twenties. Without
medical intervention, women’s fertility declines after the age of thirty-five
until they are no longer fertile one year post-menopausally. Men retain their
fertility until they die, even though there is a reduction in the amount of se-
men and the quality of sperm produced per ejaculate as they age (Aitken and
Graves, 2002; Guylaya et al., 2001; Thacker, 2004; Woolf quoted in Marino,
1993). Men also can produce chromosomal abnormalities as they age that con-
tribute to either the ability to carry a fetus to term or to fetal problems (Ait-
ken and Graves, 2002; Daniels, 1997). The heterosexual partnering pattern in
Fertility, Conception, and Differentiation 125
the United States favors men who are older than their female partners. Since
older women often are partnered with men who are older than they are, the
male’s age may then also increase the risk for chromosomal anomalies in their
children (Aitken and Graves, 2002; Daniels, 1997).
By gender, criteria for fertility become more specific. Biomedically, female
fertility is determined by age, regular ovulation, patent fallopian tubes, and
cervical mucous. In addition, as women age, the chances of Down’s Syndrome,
a chromosomal abnormality, and other pregnancy-related problems including
high blood pressure and gestational diabetes increase (Berek, Adashi, and
Hillard, 1996). Thus, women face a “biological clock” concerning fertility.
In addition to patent fallopian tubes, women need to ovulate regularly. A
woman can only become pregnant when she ovulates. Ovulatory problems are
one of the more frequent causes of female infertility (Boston Women’s Health
Collective, 1992, 2005; Speroff, Glass, and Kase, 1978; Stewart et al., 1979).
A third criterion for female fertility is tubal patency. This means open, un-
blocked fallopian tubes that allow for the union of sperm and egg and the fer-
tilized egg’s passage to the uterus. Cervical mucous is another factor in female
fertility. The texture, color, density, and amount of cervical mucous changes
during ovulation to allow sperm to pass through the os, the opening in the
cervix. See Chapter 6 for a more detailed discussion of this process. Female
fertility ultimately entails the ability to be impregnated, carry a fetus to term,
and give birth to it.
Male fertility is defined relative to sperm count, sperm motility, and sperm
form. As stated in Chapter 5, men continuously produce millions of sperm
daily from puberty until death. During the sexual arousal and ejaculatory pro-
cess, somewhere between 200 and 400 million sperm are ejaculated each time.
It is believed that the large number of sperm ejaculated help to move the other
sperm along the way to the fallopian tubes. While it takes only one sperm to
fertilize an egg, the pathway to fertilization is not a smooth one for the sperm.
Only about 200 of the sperm actually survive to reach the fallopian tubes, a
trip that takes several minutes after deposition in the vagina.
As such, sperm motility or movement is a second important variable in male
fertility. Semen aids in sperm motility (i.e., how fast and well the sperm move).
Active, fast-moving sperm have a greater chance of reaching the fallopian
tubes and being received by the egg than less active ones. A third component
of male fertility is sperm form. In gross anatomic terms, sperm are composed
of a head, midsection, and tail (see Figure 7.1). The head secretes an enzyme
to dissolve the surface coating of the egg to make sperm envelopment by the
egg possible. The mid-section contains the chromosomal material and the tail
aids in sperm motility. All three sections need to be present and functional for
impregnation to occur.
Partner physiological compatibility is necessary for conception. Partner
compatibility includes a harmonious pH balance between the woman’s vagina
and the man’s semen, thinned watery cervical mucous, and active, numerous
sperm that can pass through the os into the fallopian tubes. While fertility is
126 Fertility, Conception, and Differentiation
Figure 7.1 Complete diagram of a human spermatozoa.
assumed, its importance is not taken for granted. Fertility is important in all
societies; it is probably one of the few universal concerns in human sexuality.
This can be seen in art forms, myths, folklore, and people’s value on fertility
and kinship through time and space. Penis sheaths common among groups liv-
ing in New Guinea, Michelangelo’s sculpture of “David,” and the Washington
Monument in Washington, DC, are all examples of various cultures’ appreci-
ation of phallic forms. The Venus de Willendorf, a 25,000–year-old statuette
of a woman with pendulous breasts, a rounded stomach, and large hips and
thighs, is a commonly cited example of a female fertility symbol.
Beliefs about fertility and conception are widespread and culture-specific.
Though all human groups know that it requires penile-vaginal intercourse to
conceive, various fertility enhancers are found cross-culturally. To enhance
conception, potions are consumed, rituals are performed, seduction techniques
are encouraged, and spirits are appeased. For example, the Mayan women
of Mexico may consult a curandera, midwife, or traditional birth attendant
(TBA) relative to fertility concerns (Faust, 1988). Among the Brunei Malay,
the dukun, a healer, may be consulted for advice as well as potions to ingest
(Kimball and Craig, 1988). Among the Tiwi, which were discussed earlier,
certain female totems are believed to be responsible for conception. They can
be sought out or avoided depending on whether a woman wishes “to have life
breathed into her body” or to avoid conception (Goodall, 1971). Among the
Sambia, a horticultural group in New Guinea, fellatio (oral sex) performed on
the husband is believed to “prepare a wife’s body for childbearing by ‘strength-
ening’ her” (Herdt, 1993: 306). See Chapter 11 for a discussion of Sambian
“growing a boy.” Semen in this culture is thought of as a vital life essence
which makes and keeps men strong and healthy while ensuring female fertility
and embryonic development. Their sexual beliefs are representative of what
Barker-Benfield (1975) refers to as the “spermatic economy.” The spermatic
economy is a belief system that is widespread cross-culturally, including the
United States. It focuses on semen (i.e., ejaculate) as a precious, essential life
substance that exists in finite supply and can be “used up” in a man’s lifetime if
he is not careful about where, how, and with whom he “spends” it (ejaculates).
Sambian sexual beliefs existed in a culture in which endemic or ongoing war-
fare over scarce resources, including women, was common. Resources for food,
shelter, and water exist in limited supply due to natural boundaries, sometimes
referred to as impacted habitats. Women do most of the food procurement,
processing, and distribution. They are frequently seen as the enemy since mar-
riages are often political alliances among warring factions. Women can also
be perceived by the men as sexually voracious and potential depletors of trea-
sured ejaculate. The idea that men form the baby and women “grow it” is not
that different than European thinking of several hundred years ago when the
uterus was perceived as the receptacle of the homonucleus (little baby) “given”
by the man.
Much of the effort to ensure and protect fertility, both within and outside
the United States, rests with women. Until recently, the dominant fertility
patterns among women were extended periods of lactation followed by preg-
nancy. Continuously uninterrupted menstrual cycles, varied by one or two live
births and short or non-existent periods of lactation, are largely a middle-class,
industrial, twentieth- and twenty-first-century phenomenon (Beyene, 1989;
Frayser, 1985). Since fertility is critical to the continuation of any group, it
is a topic that is taken seriously by most of the world’s peoples. This includes
means of enhancing conception, avoiding conception as discussed in Chapter
8, and means of dealing with infertility.
Infertility is seen as a tragedy societally and individually, regardless of an
individual culture’s positions about population pressures. Infertility, or the in-
ability to conceive and bear a child, is a cause of societal and cultural concern.
When it occurs, it is almost universally grounds for divorce and individual
grief (Cohen and Eames, 1982; Ward and Edelstein, 2006: 82–83). There is
much cross-cultural variation in response to infertility. However, a fairly wide-
spread constant is that the woman is seen as being responsible for the fertility
problem (Frayser, 1985). For example, among the herding Nuer in Africa, an
infertile wife becomes a “husband” to another, assumably, fertile woman. The
female “husband” becomes the sociological father to her wife’s offspring by a
male. This practice allows the continuation of the infertile woman’s patrilin-
eage, the descent system where you trace your family through your male kin
(Cohen and Eames, 1982). As with many other cultures, the Sambia believe it
is only the woman who can be infertile. When infertility occurs in their cul-
ture, the Sambian male takes another wife, but does not divorce the allegedly
infertile wife (Herdt, 1993).
In both industrialized and nonindustrialized societies, infertility is managed
by cultural means. Common solutions can include divorce and remarriage, po-
lygyny, adopting a child, and fostering, the latter being primarily a nineteenth-
to twentieth-century, industrialized alternative. “Aunting” and “uncling” also
occur. In these situations, the infertile couple involve themselves intensively
with the children in their extended kin group. This may include financial, so-
cial, psychological, and ritual activities, similar to what occurs in the unilineal
descent groups in nonindustrialized societies. Single-parent adoptions are also
increasing for both men and women in industrialized societies. This extends
to international adoptions for singles and couples. The economic and social
flexibility that has occurred for some people in our culture since the latter part
of the twentieth century makes this option more feasible. Some international
babies are seen as easier to adopt—girls, for example, may be easier to adopt in
societies that strongly value boys (“Towards Ending Violence against Women
in South Asia,” 2004). Since most cultures have either bilateral or patrilineal
descent, boy children perpetuate the lineage and are less likely to be put up for
adoption. See Chapter 10 for definitions and discussion. Boy babies may also
be preferred because they are seen as “brighter, stronger, and healthier” than
girls (Whelehan’s counseling file).
Overpopulation may be a global concern and an issue for mainstream
groups. However, much of the nonindustrialized world as well as some eth-
nic groups in the United States such as the Amish, Hutterites, and African
Americans may perceive these concerns and attempts to impose birth control
on them as a threat of genocide by the larger society. Regardless of generalized
concerns about population pressures, for the infertile couple who wants a bio-
logical child, it is a very remote, abstract argument. Given the universal value
on fertility, the anguish an infertile couple experiences in not being able to
conceive is understandable.
In some societies, infertility is cause for divorce, grief, and loss of status,
particularly for the female. Many societies actively try to treat infertility indig-
enously either through biomedicine, potions, behavioral changes, consultation
with specialists, or gender selection (Becker, 1990; Faust, 1988; Kimball and
Craig, 1988; Malpani, 2002; Marmor, 1988).
Since much of the biomedical work on infertility has occurred in industri-
alized societies in the last decades of this century, the focus of this discussion
will be on the industrialized countries. In the United States, fertility problems
have stabilized with about 10–15 percent of the couples who are trying to
conceive and bear a child unable to do so (“Optimal evaluation of the infertile
male,” 2010: 3; “Optimizing natural fertility,” 2012; Sharlip et al., 2002). In the
United States, a couple is defined as infertile after they have been trying for a
year to have a child without success (Esteves et al., 2015: 3; “How is Infertility
Diagnosed?” n.d.; “Infertility and Fertility,” 2017; “Multiple definitions of in-
fertility,” 2016).
Physiologically, infertility may rest with the man, the woman, or the couple.
Although the statistics on causal attribution vary, roughly 35–40 percent of
the time the problem is with the male; 35–40 percent of the time the problem
is with the female; and the remaining percentage is either couple incompati-
bility, behavioral, or unknown (Berek, Adashi, and Hillard, 1996: 915; Hatcher
et al., 1986; Ragone, 1994; Stewart et al., 1979). Physiological causes for both
male and female infertility relate to the established criteria for fertility.
Male infertility can be due to low sperm count, motility problems, or de-
formed sperm. STIs (sexually transmitted infections), abusive-addictive drug
usage, and congenital problems can cause infertility in males (Aitken, Koop-
man, and Lewis, 2004; Kenkel, Claus, and Eberhard, 2001; Thacker, 2004;
Thomas, 2000). Relative to numbers, a subfertile or infertile male is one whose
sperm count is below 20–40 million sperm per ejaculate (Berek, Adashi, and
Hillard, 1996: 920; Kelly, 1988; Stewart et al., 1979). This is the most common
cause of infertility in men.
Sperm motility is another factor in infertility. As stated, sperm need to
move quickly and continuously in order to reach a fallopian tube and be able
to fertilize an egg. Slow-moving, sluggish sperm probably will not survive the
trip or be taken in by the egg. Problems with sperm motility are the second
most common cause of male infertility in the United States. Finally, a man
may produce misshaped sperm, or sperm missing one or more of its necessary
parts. A semen analysis, which notes sperm count, size, shape, and motility, is
a key diagnostic tool in a male fertility workup.
Female infertility can be caused by endogenous hormonal imbalance, ill-
nesses, or stress, as well as by STIs, endometriosis, pelvic inflammatory disease
(PID), and drug abuse or addiction. The most common form of female infertil-
ity is caused by problems with ovulation. The second most common problem is
some form of tubal blockage, followed by a combination of the two. Diagnostic
tests for female fertility problems are usually more complicated, extensive, in-
vasive, and costly than for males. These tests include hormonal assays, mea-
surements of tubal patency, and studies of cervical mucous.
The causes of couple or male-female infertility may be behavioral or phys-
iological. Behavioral problems include either too frequent ejaculatory-penile
vaginal intercourse that depletes the sperm supply,1 too infrequent ejaculatory
intercourse, or ejaculatory intercourse at times when the woman is not ovu-
lating. Physiological problems include pH imbalances between the woman’s
vagina and the man’s semen; incompatibility between the cervical mucous
and sperm, often referred to clinically as “hostile”2; and occasionally, an aller-
gic reaction by the woman to her partner’s sperm (Aitken and Graves, 2002;
Guylaya et al., 2001; Stewart et al., 1979).
Fertility may be decreased in “spermatic economies.” Infrequent p-v inter-
course reduces the chances of conception. Among some groups such as the
Sambia, Mae Enga, and other horticultural groups in Melanesia, specifically
New Guinea, p-v intercourse occurs relatively infrequently, resulting in a low
birth rate. As discussed, women in these societies are also seen as sexually
voracious, powerful, and dangerous—eager to “swallow” a man’s precious and
limited life essence (Gregersen, 1983; Herdt, 1982, 1993; Williams, 1986).
Currently, there are a wide range of treatments having variable degrees
of success available to infertile couples in the United States. Male infertil-
ity problems may be treated by isolating and concentrating his viable sperm
and then artificially inseminating his partner with them (AI-H), by artificial
insemination donor (AI-D), or combining donor-husband sperm in artificial
insemination. Generally, vitamin or drug therapies do not alleviate the con-
dition. If the vas deferens is blocked, or a varicocele, a varicose vein of the
scrotal sac, exists, surgery may be helpful.
AI-H may be more successful if the man makes love with his partner
using a condom to catch the ejaculate, rather than masturbating into
a specimen jar in a doctor’s bathroom. The greater eroticism of partner
lovemaking is believed to cause a more forceful ejaculation of younger,
fresher, healthier sperm (McCarthy, 1990; Medical Aspects of Human
Sexuality, 1991: 16).
For females, treatments may be hormonal, surgical, or both depending on the

situation. Ovulation problems often are treated hormonally. Tubal blockage
problems generally are treated surgically to remove the source of the obstruc-
tion. These treatments are revolutionary, dramatic, and can be controversial.
Some of the more controversial treatments such as in vitro fertilization (IVF),
embryo transplants, and embryo-sperm (gamete) implantation in the fallopian
tube were discussed relative to their socio-cultural implications in the previous
chapter (Peris, 2005). Even AI-D is controversial, since some adult AI-D babies
have searched for their biological fathers (Francoeur, 1989).3
Legal and social questions arise in our culture as to whether AI-D donor
files should be open to AI-D children, and as to whose rights take prece-
dent—the donor’s right to anonymity or the child’s right to know biolog-
ical paternity. It is noted that AI-D donors are medically and genetically
screened prior to being accepted as participants, that phenotype and
socio-cultural matching occurs between the donor and child’s family,
and that the donor’s medical and social history data are available to the
AI-D child’s family.
Couples’ treatments range across the behavioral-physiological spectrum. For
those infertility problems caused by intercourse-related behaviors, education
about ovulation, the timing of fertilization, and sperm supply can help to alle-
viate the situation. While this may appear to be a relatively “simple” solution,
sensitivity to the couple’s psycho-emotional state is important. Making love by
the calendar in order to conceive a child can produce anxiety, tension, specta-
toring (i.e., observing how well you are doing), and can be less than a sponta-
neous, passionate, sensuous experience for both people. Couple infertility due
to sperm-cervical mucous pH incompatibility may be treated with drugs, with
AI-H as a bypass mechanism, or with the use of condoms for a while to see if
the problem may self-correct (Stewart et al., 1979; Wright et al., 2003).
American lay and folk remedies for infertile couples abound. They include
increasing the frequency of p-v intercourse and ejaculation, which can ac-
tually decrease the sperm count; using different positions in intercourse; or
ingesting vitamins or aphrodisiacs, which enhance neither fertility nor virility.
There is anecdotal reporting of infertile couples who have conceived a child
after adopting a baby.
The inconsistent use of safer sex and the increase in sexually transmitted
infections (STIs) since the late twentieth century have resulted in a rise in fer-
tility problems that are occurring at a younger age (Coste et al., 2004; “Cur-
rent Trends Ectopic Pregnancy,” 1995; Kamwendo et al., 2000; Lipscomb et al.,
2000). The financial expense and psychological and emotional costs are great for
those affected by infertility. It is interesting that even with all the sophisticated
technology to treat problems and knowledge about infertility that we have in
this country, the responsibility for a fertility problem is still largely seen as the
woman’s. In a study of middle-class, professional couples in the San Francisco
Bay Area it was found that regardless of the physiological “cause” of the problem,
the woman was expected to somehow “fix it.” If the physiological problem was
not the male’s, he offered support to his partner, but did not assume responsi-
bility for its resolution (Becker, 1990). This is not that far from the generalized
industrial and nonindustrial response of seeing the woman as responsible for fer-
tility. About half of the infertile couples in the United States can be successfully
treated so that conception and a live birth can occur; this number can be as high
as 80 percent for women under 35 and as low as 26 percent for women age 40
and over (Malchau et al., 2017; Zieve et al., 2018). These numbers do not include
live births resulting from advanced reproductive techniques (Zieve et al., 2018).
Conception
As the preceding discussion indicates, fertility is a necessary condition for con-
ception. Biomedically, conception is the union of the sperm and egg, which is
dependent upon regular spermatogenesis and ovulation. Conception is not the
same as viability, or the ability to create and bear offspring. Viability necessitates
implantation of the fertilized egg into the endometrium and the development
and birth of a full-term fetus (Allgeier and Allgeier, 1991; Reynolds et al., 2003).
In terms of reproductive success, there is a great deal of waste. Relative to an
individual who may or may not wish to impregnate or be pregnant, conception
and viability may be akin to playing roulette.
Conception is regulated and interpreted through culture. In most cultures,
there are explanations given as to why and when intercourse results in con-
ception (Frayser, 1985; Gregersen, 1983). It is a myth in industrialized societies
that nonindustrialized groups do not know that heterosexual genital contact is
necessary for conception. That members of these societies do not openly discuss
this, particularly with researchers from industrialized societies, is not surpris-
ing. Specifics of sexual behavior and conception, particularly across gender lines
(most researchers have been and are male), are not topics of everyday conversa-
tion. Explanations for conception are embedded in people’s views of sexuality,
reproduction, and male-female relations. For example, the Tiwi, whom we dis-
cussed previously, believe that the essence of sexuality is female. Male totems,
animistic spirit beings, are important in their patrilineal kinship system; one’s
spiritual totems are inherited matrilineally through females.
A woman conceives through a given act of intercourse when her spirit totem
breathes life into her body (Goodall, 1971). Given that much of the embryonic
process is still unknown from an industrialized, technological perspective (e.g.,
Muecke, 1979; Sizonenko, 2003; Wilson, 1979) and that new knowledge about
sexuality continually unfolds, a measure of humility is needed in understand-
ing these explanations. It was only a generation ago (when your authors were
children) that we were often told that the “stork brought babies,” or that they
were picked from the “cabbage patch.” Conception occurred by a “seed being im-
planted in a woman’s tummy,”—leading a number of girls to swallow watermelon
seeds. Students in one human sexuality class reported they “knew people who be-
lieved if you had ‘sex’ standing up, you wouldn’t get pregnant because it ‘would all
fall out.’” These were (are?) common US folk beliefs about conception and birth.
Due to current and future assisted reproductive technology (ART), hetero-
sexual genital contact is no longer necessary for fertilization to occur. The full
impact of these industrialized developments on conception in both industrial-
ized and nonindustrialized societies remains to be seen (Benagiano and Bianchi,
1999; Malpani, 2002; Todosijevic, Ljubinkovic, and Arandc, 2003). Some poten-
tial consequences of these developments were presented in Chapters 5 and 6.
From an industrialized bio-behavioral perspective, there are several aspects
of prenatal sexual differentiation and post-natal phenotypic expression that
culturally define sexual physiological “normalcy.” Although there are a variety
of ways to biologically define one’s sex, as discussed in Chapter 2, from a bio-
medical perspective, four criteria need to be met. Prenatally, the establishment
of genetic or chromosomal sex and appropriate differentiation in utero need to
occur. Post-natally, appropriate gender identity, or the knowledge that you are
male or female, and gender role development and puberty (i.e., sexual adult-
hood) need to occur.
Genetic or chromosomal sex is determined at conception. Genetic or chro-
mosomal sex is the arrangement of either the XX pairing for a girl, or the XY
pairing for a boy. Although a range of chromosomal X and Y combinations is
possible and may occur, only XX or XY are genetically normal. Based on ge-
netic sex, sexual differentiation or gonadal sex develops in the fetus (Muecke,
1979; Sizonenko, 2003; “Syndromes of Abnormal Sex Differentiation,” 2005;
Wilson, 1979). Gonadal sex gives rise to phenotypic sex, or the external and
internal physical characteristics that allow a culture to label a child a boy or
girl. These characteristics include, but are not limited to, such structures as
the penis, testicles, vas deferens, or prostate in the boy, and the clitoris, ova-
ries, fallopian tubes, or vagina in a girl. At birth, a child is labeled as a boy or
girl based on visual inspection of the genitalia; the child’s sense of itself as a
boy or girl is referred to as gender identity. It is believed that children know
their gender identity by the time they are eighteen to twenty-four-months old
(Money and Ehrhard, 1972). Based on gender identity, gender role develops.
Gender role, sometimes referred to as script or scripting (Gagnon, 1979), is the
internalization and acting out of culturally defined male or female behavior, af-
fect, and attitudes. The ideal, at least in US culture, is to have genetic, gonadal,
and phenotypic sex, gender identity, and gender role synchronized so that one
looks, acts, thinks, and feels like a culturally defined boy or girl, man or woman.
The process of sexual differentiation in utero and attainment of gender iden-
tity and gender role has received a great deal of attention from the Middle Ages
through Freud to the present (e.g., Bullough, 1976; Freud, 1929 [1929]; Gagnon,
1979). Sexual differentiation, the most physiological aspect in this continuum,
has also received a great deal of scrutiny (Jost, 1972; Muecke, 1979; Sherfey, 1972;
Sizonenko, 2003; “Syndromes of Abnormal Sex Differentiation,” 2005; Wilson,
1979). These theories range from postulations that as humans we are all embryo-
logically female in our composition (Sherfey, 1972 based on Jost, 1961), to a very
complex interpretation of the hormonal-anatomical differentiation process (“Ex-
ploring the Biological Contributions to Human Health,” 2001; Wilson, 1979).
A simplified interpretation of sexual differentiation follows based on more
than sixty years of research (McCarthy and Arnold, 2011; Phoenix et al., 1959).
Genetic or chromosomal sex is determined at conception by the pairing of
either XX or XY chromosomes for a girl or boy, respectively. As part of embry-
onic development regardless of genetic sex, the following schema occurs:
• The embryo is sexually undifferentiated for the first six weeks of life. Phe-
notypic sex cannot be determined by visual observation.
• Both male and female embryos contain both the Mullerian ducts, which
will develop some female sexual and reproductive structures, and Wolffian
ducts, which will develop some male sexual and reproductive structures.
• The Wolffian ducts develop part of the urinary tract system in both males
and females, specifically the ureters, the collecting tubules of the kidneys,
and part of the bladder.
• The presence of Wolffian ducts is a necessary condition for Mullerian duct
development in the female (“Exploring the Biological Contributions to
Human Health,” 2001b; Muecke, 1979; Sizonenko, 2003).
In the male, the following process occurs. At about six weeks of embryonic de-
velopment, the male begins to sexually differentiate. Several hormones are re-
leased by the embryo to expedite this process. They are testosterone, the H-Y
antigen,4 both of which facilitate male anatomic development, and Mullerian
inhibiting substance (MIS), which closes the Mullerian ducts and causes them
to atrophy (“Exploring the Biological Contributions to Human Health,” 2001;
Sizonenko, 2003; Wilson, 1979). Based on the hormone release and the XY
chromosomal arrangement, the penis, testes, and scrotum develop. The Wolf-
fian ducts develop into the rete testes (a rudimentary structure) the epididymis
and vas deferens. During the course of fetal development and with the help
of testosterone, the other accessory organs appear (e.g., prostate, seminal ves-
icles). The testicles descend into the scrotal sac during the third trimester. If
all goes well, approximately nine calendar months after conception an infant
is born. The infant is then typically given the gender identity of a boy, and his
formal gender role socialization begins.
A girl’s differentiation process begins later, around ten to twelve weeks of
fetal development.5 Although estrogen may be involved in later prenatal de-
velopment, its role, if any, in the differentiation process is not as clear as is
testosterone in the male’s (“Exploring the Biological Contributions to Human
Health,” 2001; Hyde, 1994; Wilson, 1979). The Wolffian ducts spontaneously
close in the female. A Wolffian inhibiting substance, analogous to MIS, does
not exist. The genital tubercle, homologous and analogous with the males, de-
velops into the clitoris. The Mullerian ducts develop into the uterus, fallopian
tubes, broad ligament, and upper third of the vagina with the other accessory
organs (e.g., labia minora) following. The presence of an X chromosome in
both males and females, the need for MIS and testosterone release in the male
and lack of comparable hormone release in the female, the live birth of an X or
XO “female” and not of a Y or YO male, all lead some researchers (e.g., Sherfey,
1972) to take a strong stand that human embryos are innately female.
Intersexuality
As stated, only XX or XY arrangements are considered to be normative genetic
sex in this culture. There are, however, a number of other X and Y combi-
nations that can occur. Three of the most common are Turner’s Syndrome,
Klinefelter’s Syndrome, and the XYY Syndrome. Turner’s Syndrome, repre-
sented by an X or XO combination, occurs in about 1:2,500 to 1:4,000 live
births (Cui et al., 2018; Davenport, 2010; Oktay et al., 2016; Sybert and Mc-
Cauley, 2004). Klinefelter’s Syndrome, represented chromosomally as XXY,
occurs in about 1/500 to 1/900 live births (Dahl et al., 2018: 79; Davis et al.,
2016: 15; Salemi et al., 2016: 408). The XYY Syndrome, formerly known as the
“Supermale Syndrome,” occurs in about 1/1,000 live births (Kim et al., 2013;
Liao et al., 2011; Linden et al., 2002). See Table 7.1 for a description of these
and additional forms of intersexuality.
It is estimated that only 1 percent of fetuses with Turner’s Syndrome are likely
to survive long enough to be born (Morgan, 2007; Papp et al., 2006). Turner’s
Syndrome individuals often have a number of severe physiological problems and
frequently die in their twenties. They are sterile, have incomplete or rudimen-
tary ovaries, uterus, and fallopian tubes, a blind vagina that may be corrected
surgically, immature post-pubertal external genitalia, are often short, and have
webbed neck or fingers (Money and Ehrhardt, 1972). Webbing is a fold of skin
between the neck and shoulder or digits. Turner’s Syndrome individuals may
have cognitive development problems (Mange and Mange, 1980; Stine, 1977).
Although they have some female phenotypic sex characteristics, they do not
meet the criteria of normative genetic and physiological development presented
earlier in this chapter. Turner’s Syndrome individuals chromosomally represent
the single X chromosome that some writers have used to postulate the innate fe-
maleness of the human embryo. Single X chromosome individuals are not physi-
cally normative females either. This position is believed by Bolin and Whelehan
to be a feminist bias, since an X or XO female is not a physiologically normative
female. This politicization of the embryo (i.e., that males are “incomplete” since
they need hormonal release during differentiation to become a phenotypic male
and without it would develop female characteristics) may be a backlash reaction
by some feminist researchers. The backlash could be a reaction against Freudian
interpretations of the clitoris as a “half-formed” penis and the vaginal orgasm
myth (1959 [1929]), as well as a general industrialized tendency to present male
culture as total culture in which women are defined in terms of their relation-
ships to men. Perhaps bias needs to be recognized more openly whenever it is
found to avoid politicizing the differentiation process.
Klinefelter’s Syndrome (XXY) individuals have an essentially male pheno-
type. They are sterile and tend to have underdeveloped primary and second-
ary sex characteristics. Atrophied testicles6 produce low levels of testosterone,
frequently resulting in gynecomastia, or breast enlargement, low libido, prob-
lems with erectile ability, and more fat than muscle mass per overall body
composition. In essence, both male and female secondary sex characteristics
appear. Some XXY individuals’ psychological development has been labeled
schizophrenic, which may be more perceived than real (Mange and Mange,
1980; Money and Ehrhardt, 1972).
The XYY Syndrome receives attention because of the alleged aggressive and
physically violent tendencies of these individuals. According to some theorists
(Allgeier and Allgeier, 1991), the extra Y chromosome produces men who are
not only taller and more muscular than XY males, but who also have a greater
propensity for acting out violently. Many of these studies are methodologically
flawed (Allgeier and Allgeier, 1991). About 50 percent of the XYY males are
sterile. See Table 7.1 for a description of behavioral characteristics.
All three of these syndromes (Turner’s, Klinefelter’s, and XYY) are believed
to occur randomly. Since both Turner’s and Klinefelter’s Syndrome individuals
are sterile, they are self-limiting. They do not reproduce. Fertile XYY males do
not appear to be more likely to produce XYY sons than XY males. Causes of
these chromosomal variations are unknown (Mange and Mange, 1980).
The essence of being male or female is important as a defining characteristic
and is culturally valuable. It can include substances such as semen or menstrual
Table 7.1 Summary of anomalies of prenatal differentiation
Name Cause Basic clinical features Frequencies
Congenital Adrenal Genetically inherited malfunction In XX children, can cause mild to severe masculinization of genitalia at One in 15,000
Hyperplasia (CAH) of one or more of six enzymes birth or later; if untreated, can cause masculinization at puberty and
involved in making steroid early puberty. Some forms drastically disrupt salt metabolism and are life-
hormones threatening if not treated with cortisone.
Androgen Insensitivity Genetically inherited change in XY children born with highly feminized genitalia. The body is “blind” One in 50,000 to
Syndrome (AIS) the cell surface receptor for to the presence of testosterone, since cells cannot capture it and use it one in 20,000
testosterone to move development in a male direction. At puberty these children
develop breasts and a feminine body shape.
Turner’s Syndrome Females lacking a second X A form of gonadal dysgenesis in females. Ovaries do not develop; stature is One in 2,500 to
chromosome (XO) short; lack of secondary sex characteristics; treatment includes estrogen one in 4,000
and growth hormone. births
Klinefelter’s Syndrome Males with an extra X chromosome A form of gonadal dysgenesis causing infertility; after puberty there is often One in 500 to one
(XXY) breast enlargement; treatments include testosterone therapy. in 900
Ovotesticular Disorder Usually XX chromosome, more More commonly born with both testicular and ovarian tissue; combination One in 100,000
of Sex Development rarely XY or mosaic. Some of ovaries and testes. Sometimes has a male side and female side; or grow births
(ovotesticular DSD; evidence of family history together in one organ. Appearance of external genitals varies considerably
true gonadal intersex; Cause in XX unknown, possible in terms of intermediate states.
true hermaphroditism gene translocation from Y
XYY Syndrome The extra Y is not an inherited This condition was called SuperMale Syndrome because some early flawed Frequency: one in
(formerly called condition but due to an error studies found a high number of prison inmates with XYY; they were 1,000. However
Supermale in cell division in the fertilizing also thought to be overly aggressive. Subsequent research has disproved this number is
Syndrome) sperm or in developing embryo this stereotype. XYY males typically have no distinctive characteristics conservative,
although they may be slightly taller than average and about 50% have since many men
learning disabilities although mild. with XYY are
unidentified
Source: Adapted from: Auchus, 2010; van der Kamp and Wit, 2004; Gottlieb and Trifiro, 2017; Genetics Home Reference National Institutes of Health: “Androgen
Insensitivity Syndrome” (https://ghr.nlm.nih.gov/condition/androgen-insensitivity-syndrome#statistics); Oktay et al., 2016; Cui et al., 2018; Davenport, 2010; Sybert and
McCauley, 2004; Dahl et al., 2018; Davis et al., 2016; Salemi et al., 2016; Nistal et al., 2015; Kim et al., 2013; Liao et al., 2011; Linden et al, 2002; Sax, 2002.
Note: Total number of people whose bodies differ from the normative male or female is one in 1,500–2,000 (ISNA: “How Common is Intersex?”).
blood as well as spiritual, aesthetic, kinesics, or occupational attributes. There-
fore, cross-culturally a man can be phenotypically and genetically male, but be
labeled female or something else (i.e., “not man” or “near man”) by his affect,
demeanor, or special talents as exemplified above. Similarly, a phenotypic and
genotypic female may succeed in being a warrior woman (Williams, 1986).
With the Sambia, oral intercourse among adolescent males is seen as a way of
preserving and recirculating semen—a vital, life-sustaining fluid believed to
exist in finite quantities. Male-male fellatio during adolescence builds up male
energy (jergunda). Accumulating jergunda allows him to fulfill his sexual obli-
gations as a husband and semen-nurturer to his unborn children. By definition,
then, p-v intercourse is a potential drain of this energy and therefore must be
carefully controlled (Herdt, 1982). These male gender role expectations are
valued and fulfilling them grants status and respect to men.
Summary
1 Fertility, infertility, and conception are bio-behavioral phenomena.
2 There are a number of technological procedures in industrialized cultures
to deal with infertility problems.
3 There are a number of theories used to explain sexual differentiation in
utero. Some theories used to explain transgender identity and homosexu-
ality rely on interpretations of the differentiation process.
4 Genetic or chromosomal sex, hormonal, or gonadal sex, phenotypic sex,
gender identity, and gender role are cultural terms used to explain the pre-
natal differentiation process and post-natal development of identity and
roles in the United States.
5 Turner’s Syndrome, Klinefelter’s Syndrome, and the Supermale Syndrome
are variations of XX or XY chromosomal arrangements.
1 How are phenomena such as fertility, conception, and gender culturally
influenced and expressed?
2 What are the controversies around ART and what are the potential
changes in human reproduction as a result of ART?
Suggested Resources
Websites
ISNA Intersex Society of North America (http://www.isna.org). Last accessed 11/09/07.
Sizionenko, P. C. 2003. “Human Sexual Differentiation.” Geneva Foundation for Med-
ical Education and Research. http://www.gfmer.ch/Books/Reproductive_health/Hu-
man_sexual_differentiation.ht.
8 Birth Control, Abortion, and
Methods of Birth Control in
Cross-Cultural Contexts
Chapter Overview
1 Defines key terms and concepts related to birth control including contra-
ception, population, fertility, mortality, migration, theoretical effective-
ness rate, actual/use effectiveness rate, and woman years.
2 Compares and contrasts population trends between industrialized and
nonindustrialized nations.
3 Examines industrialized, nonindustrialized, and indigenous approaches to
birth control.
4 Explains various birth control and contraceptive methods.
5 Discusses prevalence and availability of various kinds of contraceptive
techniques globally with reference to policy and unmet needs in industri-
alizing nations.
6 Provides an overview of abortion trends and practices in the United States
including the historical and political context.
7 Explores abortion trends in industrializing/nonindustrialized nations.
8 Summarizes preindustrial and traditional methods of birth control in a
cross-cultural and historical context.
Birth Control: Practices and Prevalence in Industrialized

and Nonindustrialized Nations
Dramatic changes have occurred in terms of overall population in the world.
The time it took for the earth’s population to reach the first billion spanned
from Homo sapiens around 150,000 years ago to 1850. By 1930, it took only
eighty years to reach the second billion; in the course of another thirty years,
the third billion. Circa 1976, the world’s population reached 4 billion (Gordon
and Snyder, 1986: 155). By 2019, the world population climbed to 7.7 billion
people. This represents a gain of 86 million people annually and 1.6 billion
more than in 2000. By 2050, it is estimated that world population will reach
9.7 billion people (World Population Prospects, 2019). Because sex research,
scholarship, and statistical evidence are generated continuously, readers are
encouraged to update the data we present.
Before venturing into our discussion of birth control in the United States or
globally, it is important to define our terminology. Birth control refers to any
Birth Control, Abortion, and Culture 139
method whereby births are prevented and includes any method for controlling fer-
tility (including contraceptive methods) through birth spacing, late marriage, long
postpartum sex taboos, herbs, abortions, etc. Contraception refers to methods
that interfere with the fertilization of an ovum by sperm and include barrier, hor-
monal, and surgical means. Therefore, abortion is considered a method of birth
control, but not a contraceptive method, since it terminates an established preg-
nancy. In popular usage and some of the literature these terms (birth control and
contraception) are often used interchangeably although sometimes inaccurately.
Population control is an abstract concept used to discuss major demographic
trends that includes births, deaths, and migrations. Fertility, on a population, is a
measure of the rate at which people are born. Mortality is a measure of the rate of
deaths. Migration is defined as the “movement of people into or out of a geograph-
ical area” (Eshleman, Cashion, and Basirico, 1988: 591). Until approximately 200
years ago, high death rates with high birth rates maintained worldwide population
stability. In 1850, a major demographic transition occurred in which birth rates
continued at high levels while death rates decreased. Death rates declined because
of improved diet and advances in preventative medicine and treatment as well as
improvement in public health measures such as clean drinking water and safer
disposal of waste (Bates and Fratkin, 2003; Gordon, 1978: 513). These trends cre-
ated a period of explosive population growth. However, gradually, family planning
and birth control methods began to have an impact, and the rapid growth was
moderated (Eshleman, Cashion, and Basirico, 1988: 595).
Although industrialized nations followed this pattern, the transition may
not yet be completed in nonindustrialized countries (Gordon and Snyder, 1986:
155; Wells, 1978: 517–518; World Population Prospects, 2019). For example, al-
though the world’s population continues to increase overall, this is almost ex-
clusively a result of population growth in the industrializing nations. Fertility
is below replacement levels in the most industrialized nations (1.75 children
per woman), while it is still high (but declining) in the least industrialized
countries (with the highest rate at 4.6 children per woman in sub-Saharan
Africa, down from 6.3 in 1990). People are living longer as a whole, but the
least industrialized countries still lag 7.5 years behind the world average (72.6
years in 2019). This differential is primarily due to high child and maternal
mortality, violence, war, and HIV/AIDS (World Population Prospects, 2019).
A United Nations report has summarized the differences in population trends
between industrialized and nonindustrialized nations:
• Between 2019 and 2050, it is predicted that the population of the more
industrialized countries as a whole will decline slowly by about 1 percent a
year. Out of the 2 billion expected to be added to the global population in
that timeframe, the least industrialized countries are projected to account
for 1.5 billion (an annual increase of 48 million).
• The number of low-fertility (below 2.1 live births per woman) countries
continues to grow, and now includes all of Europe and North America,
China, Brazil, Bangladesh, Russia, Japan, and Vietnam. Notably, this is
not exclusively a trend among the most industrialized countries.
140 Birth Control, Abortion, and Culture
• Between 2010 and 2020, international migration has become a major fac-
tor in the population changes of some countries. This migration is pri-
marily driven by either economic opportunities or by flight from areas of
conflict.
• The population of the least industrialized forty-seven countries is pro-
jected to almost double, going from 1 billion in 2019 to 1.9 billion in 2050.
• Predictions of overall worldwide fertility declines are contingent on access
to family planning, especially in industrialized countries (World Popula-
tion Prospects, 2019).
If we assume fertility as the norm, the relative chances of conception in a year

of unprotected intercourse are 85–90 percent (King, 2005; King, Camp, and
Downey, 1991: 130). This is important information for a sexually active het-
erosexual couple trying to evaluate the effectiveness of contraceptive methods
over the course of a year. Two strategies for assessing contraceptive effective-
ness are used. The theoretical effectiveness rate refers to the percentage of
couples who would conceive using a particular technique correctly and sys-
tematically. The actual/use effectiveness rate is lower than the theoretical
effectiveness rate since not all couples use birth control methods properly or
consistently. The effectiveness of a technique is reported in terms of the num-
ber of failures per one hundred couples in a year of use called a woman year,
since women are the people who are impregnated. Over time the chances for
pregnancy increases with any technique.
For example, a technique with a 5 percent failure rate the first year will
increase to between 23 and 40 percent over the course of ten years (Fu et al.,
1999; King, 2005).
The problem of unwanted pregnancy is far more complex than just an issue
of access to contraceptives and birth control. Although the middle and upper
classes in the United States, dominated by white people, may be more aware
of birth control methods through the availability of sex education informa-
tion (remembering the constraints of national and state policy), this is not
necessarily true for the lower socio-economic classes, including various ethnic
groups, and immigrant populations. In addition, the cultural context for birth
control and family planning programs must consider age and generation, sta-
tus, gender, religion, economics, cultural pluralism, and other factors including
the impact of globalization. Sexuality education programs may not be sensi-
tive to the cultural variation in the domestic arena and globally. For example,
Mohammadi et al. (2006) found that despite religious codes that prohibit sex
before marriage, 28 percent of their sample of 1,385 Tehran males aged fifteen
to eighteen had engaged in sexual activity but were not knowledgeable about
contraceptives or STI/HIV transmission. These patterns of sexual behavior
were associated with the use of the internet, drugs, cigarettes, and alcohol as
well as work experience and living apart from their families. Another example
from Vietnam is also illustrative of cultural influences on sexuality and con-
traceptive choices. The industrial emphasis on individuality and autonomy
in sexual decision making would not be a culturally appropriate model for
Vietnam. For Vietnamese, birth control in the 1980s through the early 1990s
was used only by married couples with the input and approval of the couples’
parents. For the Vietnamese then, contraception was a family concern, not
an individual choice. Consequently, class and cultural bias occur in terms of
access to information, availability of birth control methods, and societal and
economic support (Taylor and Ward, 1991: 129).
Other factors must also be considered in understanding how people choose
contraceptive techniques. For example, there are distinct age and gender dif-
ferences in choices of contraceptives among men and women in the United
States. Recent studies report the following:
• Although three fourths of men and women rely on condoms for their
first experience, this declines with age (“Contraceptive Use in the United
States: Fact Sheet,” 2018; “National Survey of Family Growth,” 2017).
• Only 18 percent of women and 25 percent of men aged 15–44 had used a
condom in the past month (Copen, 2017: 1).
• The majority of sexually active people still favors female contraceptive
methods: approximately 20 percent of women get sterilized, compared to
10 percent of men. For women ages 40–44 the rate more than doubles to
47 percent (“Contraceptive Use in the United States: Fact Sheet,” 2018;
“National Survey of Family Growth,” 2017; “Trends in Contraceptive Use
Worldwide,” 2015).
• As people age, consistent use of condoms decreases for both women and
men. For instance, among youth ages 15–19, 36 percent of women and 53
percent of men reported having used a condom on each sexual encoun-
ter over the past year. For adults ages 35–44, these numbers decreased to
9 percent of women and 11 percent of men (Copen, 2017: 3). As noted
previously, there is a corresponding increase in female sterilization among
women in the latter half of this age group.
Researchers in Brazil have found that women who had three or more children
were more likely to choose sterilization as a method of birth control and were
less knowledgeable about other methods of birth control. Having children was
also found to be initiated earlier among Brazilian women with more than three
children and they also had a lower income than women with fewer children
(Leone and Hinde, 2005; Tamkins, 2004). These findings may help explain
Brazil’s high sterilization rate for women; 50 percent of women aged thirty-five
and older had been sterilized according to 1966 data offering historical depth
to this practice. Subsequently, sterilization has continued as a popular method
and may account for the declining fertility of Brazil recorded for the second
half of the 1970s. Researchers suggest that education about contraception
should be provided for adolescent women since this is the age they are making
reproductive choices and need to be informed about effective reversible meth-
ods (Leone and Hinde, 2005; Tamkins, 2004).
In a classic piece of research, Luker (1977) suggested a gendered theory

of “contraceptive risk taking.” What happens, according to this theory,
is that a woman engages in a cost and benefit analysis of using contra-
ception so that if the costs of contraception outweigh the perceived risk
of pregnancy, then unprotected intercourse is likely to occur. The costs
to women of using contraceptives are social in that their reputations are
at risk in terms of self-concept and peer approval. The double standard,
although modified, still prevails and affects the contraception decisions
of females. A public “coming out” as sexually active may be expressed
by purchasing over-the-counter contraceptives at a drugstore or making
an appointment to see a physician. This necessarily has emotional and
psychological consequences for the individual and relations with peers
and family. As students, do you think the double standard for women’s
use of contraceptives is still in effect among your peers?
Motives in choice of contraception and methods used vary. Some forms of

contraception, such as condoms, reduce spontaneity. This may be perceived
by women as a potential problem in their relationships with men. They may
fear the possibility of being rejected or abandoned by their partners should
they ask them to use contraception, or in some contexts they may even be
at risk for violence. Issues of women’s power to mediate the use of condoms,
for example, are important in understanding women’s risk for STI/HIV, preg-
nancy, and physical harm. Moore’s (2006) study of how sex is negotiated by
Brazilian women has implicated the importance of gendered ideologies. In
order to be regarded as “girls to marry,” rather than “girls to date,” women
were expected to be sexually ignorant and passive. Yet, women were also un-
der pressure to give in to demands for sex. There is a pervasive belief among
Brazilian women that there are extremely negative consequences to saying no
to sex with a man. Moore (2006: n.p.) concluded that the sexual system is a
coercive one because “women engage in unwanted sexual intercourse because
they believe their partner will otherwise abuse or abandon them even if no
threat is made….”
There are also young women for whom pregnancy is regarded as a positive
event, a quick ticket to adulthood and status for those who have not reck-
oned with the economic realities of childrearing as a single parent or as a
young couple. It is important to consider the cultural meaning of pregnancy
and sex, as well as its socio-cultural matrix, including socio-economic factors,
male-female relations, power inequities, and ethnic, issues when evaluating
contraceptive use.
A wide array of modern contraceptive options is available in the world today.
Table 8.1 illustrates the prevalence of various kinds of contraceptive techniques
Table 8.1 Contraceptive methods among married and in-union women ages 15–49 by
world region, percentage of population, and type
Region Any contraceptive Two most prevalent

method (%) methods (%)
Europe 69 Pill (22)

Condom (17)
Latin America and the 73 Female sterilization (26)
Caribbean Pill (15)
North America (Canada 75 Female sterilization (21)
and the United States) Pill (16)
Australia/New Zealand 69 Pill (29)
Condom (14)
Oceania (Melanesia, 39 Female sterilization (11)
Micronesia, Polynesia) Injectable (11)
Pill (6)
Africa 33 Injectable (10)
Pill (9)
Asia 68 Female sterilization (24)
IUD (17)
Source: Data compiled from information from “Trends in Contraceptive Use Worldwide 2015,”
United Nations Department of Economic and Social Affairs Population Division, 2015.
found in nonindustrialized and industrialized societies. These methods in-

clude abstinence, “natural” methods referred to as rhythm methods, barrier
contraceptives, spermicides, hormonal contraceptives, intrauterine devices,
and surgical methods (“Birth Control,” 2006; “Birth Control Guide,” 2003).
However, birth control is not a recent invention or one limited to modern
nation states. Women and men throughout history and around the world have
developed ways to control births and population, some more effective than
others. Cross-culturally and historically these have included coitus interruptus;
prolonged abstinence; various approaches to safe periods in a woman’s cycle
(rhythm methods); extended breastfeeding (lactational amenorrhea method);
oral contraceptive recipes; douching; blocking the eye of the cervix; use of
oral abortificants; abortion; and infanticide among others (Riddle, 1992, 1997;
Ward and Edelstein, 2006). See the discussion under “Traditional methods of
birth control in cross-cultural context.”
Birth control methods described for industrialized society are often referred
to as “modern” methods by national and international agencies, although we
know some are not so modern at all. Box 8.1 “Birth control methods guide,”
excerpted from the “Birth Control Guide of the Food and Drug Adminis-
tration” (2018) and other sources, offers a summary of birth control options
available in the United States as well as generally worldwide, although access
and hence prevalence rates differ domestically and internationally. This table
also includes failure rates, risks, protection from STIs/HIV, convenience and
availability, possible medical problems, and contraceptive benefits
BOX 8.1 BIRTH CONTROL METHODS GUIDE
1) Male Condoms
FDA approval: Latex: before approval required/Polyurethane: 1989,
cleared; 1995, marketed.
Side effects and health risks: May develop an allergic reaction
especially to people with latex. If either partner is allergic to latex use
polyurethane condom.
Protection from STIs: Best protection against STIs except for ab-
stinence. Very effective in preventing HIV when used consistently and
correctly.
Failure rate (births per one hundred women)a: Eleven1,2
Convenience: Placed in position before intercourse and worn during
intercourse then immediately discarded.
Availability: No doctor’s visit. Free or low cost from health depart-
ment or drugstore.
2) Female Condoms
FDA approval: 1993
Side effects and health risks: Irritation or may develop allergic reac-
tion to material (usually not serious).
Protection from STIs: Protection from STIs and HIV transmission;
not as safe as a male latex condom.
Failure rate (births per one hundred women)a: Twenty-one
Convenience: Used immediately before and worn during intercourse.
Availability: No doctor’s visit.
3) Diaphragm with Spermicide

FDA approval: FDA approval: before approval required; Caya Con-
toured Diaphragm (one-size-fits-most) approved in 2014.
Side effects and health risks: Occasional reaction to spermicide;
urinary tract infection; risk of toxic shock syndrome (rare).
Protection from STIs: No protection known at this time from STIs
or HIV.
Failure rate (births per one hundred women)a: Seventeen2,3,5
Convenience: Placed in position immediately before and worn during
intercourse. Remains in position six hours after intercourse. May need
to be refitted after abortion or weight loss/gain. May become dislodged
in certain positions.
Availability: Must visit the doctor for prescription. Doctor must re-
check yearly. Caya Contoured Diaphragm does not require a pelvic
exam to be fitted.
4) Lea’s Shield with Spermicide

FDA approval: 2002
Side effects and health risks: Made of silicone, the risk of allergic
reaction is slim. May increase chance of toxic shock syndrome, bladder
and vaginal infections.
Protection from STIs: Some protection against STIs like gonorrhea
and chlamydia but none against herpes, HPV, or HIV. Recommended
that men use condoms in association with this method.
Failure rate (births per one hundred women)a: Fifteen
Convenience: Used immediately before and worn during inter-
course. Does not need to be sized by a physician. Should be washed
after use.
Availability: Must visit the doctor for a prescription.
5) Cervical Cap with Spermicide

FDA approval: Fem cap, 2003 (the earlier Prentiff Cap is no longer sold
in the United States).
Side effects and health risks: May experience some irritation or an
allergic reaction. Pap smears may be abnormal and suffer erosion of the
cervix. Risk of toxic shock syndrome (extremely rare).
Protection from STIs: While the spermicide kills the sperm, there is
no evidence that it protects against STIs or HIV.
Failure rate (births per one hundred women)a: Seventeen or
twenty-three (depending on make of device)2,4,5
Convenience: While it may be applied up to forty-eight hours before
intercourse, it is difficult to insert. Sizing can be a problem for some
women. May be dislodged if positions change.
Availability: Must visit the doctor for prescription.
6) Sponge with Spermicide

FDA approval: 1983 (not currently on the market).
Side effects and health risks: May cause irritation to the vagina and
occasional dryness to the area. Could lead to toxic shock syndrome and
abnormal Pap smears.
Protection from STIs: While the spermicide kills the sperm, there is
no evidence that it protects against STIs or HIV. Frequent use of sper-
micides alone or in combination with other barrier methods may cause
skin irritation in the lining of the vagina and may increase the risk of
STI infection.
Failure rate (births per one hundred women)a: Fourteen to
twenty-eight4,5
Convenience: Difficult for some women to remove after use. Can

remain in place for forty-eight hours without needing additional
spermicide.
Availability: No doctor’s visit required. Not currently on the market
in the United States.
7) Spermicide Alone
FDA approval: Before approval required. Since November 2002, only
one active ingredient has been allowed.
Side effects and health risks: May cause allergic reactions and gen-
ital irritation or rash. May develop urinary tract infection. Skin rash.
Protection from STIs: While the spermicide kills the sperm, there
is no evidence it protects against STIs or HIV. Spermicide may irritate
vaginal tissue and can increase the risk for HIV.
Failure rate (births per one hundred women)a: twenty to fifty
Convenience: Time differential for applying depending on type cho-
sen. Can be used as part of sex play. Can be messy.
Availability: No doctor’s visit required.
8) Oral Contraceptives (Combined Pill)

FDA approval: First in 1960; most recent, 2003.
Side effects and health risks: May cause dizziness and nausea.
Women may experience changes in menstruation and possible weight
gain. In extreme cases, other health risks include high blood pressure,
chance of blood clots, strokes, and heart attacks.
Protection from STIs: None
Failure rate (births per one hundred women)a: one to two
Convenience: Very convenient but must be taken on a daily schedule
without fail. If the chewable tablet is used, eight ounces of liquid must
be drunk immediately after the pill is taken.
Availability: Must visit the doctor for prescription.
9) Oral Contraceptives (Progestin-only, Minipill)

FDA approval: 1973; most recent, 2019.
Side effects and health risks: May lead to women experiencing irreg-
ular bleeding, breast tenderness, and weight gain. In extreme cases, may
also experience an ectopic pregnancy.
Failure rate (births per one hundred women)a: Two
Convenience: Very convenient but must be taken on a daily schedule

without fail.
10) Oral Contraceptives (Ninety-one-day Regimen—Seasonale)

FDA approval: 2003
Side effects and health risks: May cause dizziness and nausea.
Women may experience changes in menstruation and possible weight
gain. In extreme cases, other health risks include high blood pressure,
chance of blood clots, strokes, and heart attacks. May experience some
bleeding and spotting between periods.
Failure rate (births per one hundred women)a: One to two
Convenience: Very convenient but must be taken on daily schedule.
Since a woman will experience fewer periods, pregnancy should be con-
sidered if a scheduled period is missed.
11) Patch (Ortho Evra)

FDA approval: 2003
Side effects and health risks: Women may experience bleeding be-
tween periods and breast tenderness. Mood changes can occur and some
experience nausea and headaches. In extreme cases, may increase risks of
heart attack, strokes and blood clots in women over the age of thirty-five.
Failure rate (births per one hundred women)a: One to two (weight
could be a factor)
Convenience: Patch is worn for a three-week period and not worn
during the fourth week. It is recommended that medicine and herbs
be checked as some make the patch ineffective. Patch must be used as
directed to be effective.
12) Vaginal Contraceptive Ring (NuvaRing)

FDA approval: 2001
Side effects and health risks: Vaginal discharge and irritation. Breast
discomfort, headaches, and nausea are common. In extreme cases,
women may experience blood clots in the legs. Increased risk of heart
attacks and strokes and in extreme cases liver tumors.
Failure rate (births per one hundred women)a: One to two

Convenience: Inserted into the vagina, it remains in place for three
weeks and then removed for one. If the ring is expelled from the body,
another birth control method must be used for seven days until ring has
been re-established in the body for six days.
13) Post-coital Contraceptive (Preven and Plan B)

FDA approval: 1998–1999
Side effects and health risks: Nausea, vomiting, headaches, dizziness,
lower abdominal pain are common side effects which stop within a day
or two. Some experience unexpected bleeding from the hormones.
Failure rate (births per one hundred women)a: Eighty percent re-
duction of risk in pregnancy for single act.
Convenience: Use must be within seventy-two hours of unprotected
sex. Cannot be taken before sex. Some prescription drugs hinder its
effectiveness.
Availability: As of November 2006, Plan В does not need a prescrip-
tion and can be bought over the counter by men and women over the
age of eighteen. Some pharmacists have refused to sell the drug.
14) Injection (Depo-Provera)

FDA approval: 1992
Side effects and health risks: Headaches, depression, dizziness, weight
gain are common side effects. Side effects may include breast tenderness,
nervousness, nausea. Irregular menstrual bleeding, possible bone loss, and
ectopic pregnancy are more severe risks.
Failure rate (births per one hundred women)a: Less than one
Convenience: Extremely effective. One injection every three months
and there is no daily regime. There are few hormonal side effects.
Women cannot discontinue its use for three months after injection.
Availability: Must visit the doctor for an injection.
15) Injectiona (Lunelle)

FDA approval: 2000
Side effects and health risks: Women can experience changes in
their menstrual cycle, vaginal bleeding, weight gain, headaches, and
breast tenderness. In extreme cases, the drug can lead to blood clots,
heart attacks, strokes, gallbladder disease, or liver tumors.
Convenience: Extremely effective. One injection every month. A woman
can attempt a pregnancy after being off the injections for three months.
Availability: Must visit the doctor for the injection.
16) Implant (Norplant)

FDA approval: 1990. No longer available except for those presently us-
ing device.
Side effects and health risks: Women may experience headaches,
dizziness, nausea, acne, weight gain, breast tenderness, and nervous-
ness. Also, enlargement of the ovaries and irregular menstrual bleeding.
Blood clots, ectopic pregnancies, and infection are not rare.
Convenience: While an outpatient surgical procedure, the device is
effective for up to five years. No pills or hormone effects are seen. If the
woman decides to get pregnant, the device must be removed through
outpatient surgery.
Availability: No longer available. Must visit the doctor to arrange
the procedure.
17) IUD (Intrauterine Device)

FDA approval: “Some IUDs were sold before premarket approval was
required in 1976. Those products are no longer on the market” (FDA,
12/2003).
Side effects and health risks: The main side effect is cramping and
heavy menstrual discharge. May cause irregular bleeding or no periods
(amenorrhea). While no proof, some fear it could lead to pelvic inflam-
matory disease. Perforation may occur upon insertion to the wall of the
uterus. Infertility.
Convenience: After insertion by physician, the device may be used
from one to ten years. The device does not change menstrual cycle. It
can introduce bacteria into the uterus and may be ejected or become
incorrectly positioned.
Availability: Doctor must insert the device.
18) Rhythm Method/Basal Body Temperature Method (Periodic

Abstinence)
FDA approval: NA
Side effects and health risks: None
Failure rate (births per one hundred women)a: Twenty
Convenience: Women must know their body functions including pe-
riod regularity and body temperature. If judged inaccurately, pregnancy
could result.
Availability: Healthcare providers can usually supply information to
be used for determining the periods when pregnancy is most likely.
19) Transabdominal Surgical Sterilization—Female (Falope Ring,

Hulka Clip, Filshie Clip)
FDA approval: “Sold before premarket approval was required
(1976)” (FDA, 12/2003). Falope Ring, 2010; Filshie Clip, 2016; Hulka
Clip, 1996.
Side effects and health risks: Surgical complications are a possibility
along with pain, bleeding and the chance of infection. Slight risk of
ectopic pregnancy.
Convenience: One-time procedure that requires an abdominal incision.
The woman’s fallopian tubes are blocked, thus pregnancy is prevented.
Availability: Doctor’s visit and surgery.
20) Sterilization Implant—Female (Essure System)

FDA approval: FDA restricted the sale of Essure on 4/9/2018.
On December 31, 2018, Bayer stopped selling and distributing the

Essure device in the United States. Health care providers can im-
plant Essure up to one year from the date the device was purchased.
Bayer will continue to implement the FDA’s restriction on sale and
distribution of Essure from April 2018, to ensure women are fully
informed of the risks associated with the device.
(FDA, 5/2019)
Side effects and health risks: Pain can be experienced after insertion
of tube through minor surgery. “Considered permanent as reversal is
typically unsuccessful (FDA 12/03).”
Convenience: Device is inserted by minor surgery into the vagina
by catheter. Scar tissue forms in fallopian tubes preventing conception.
Another birth control method must be used for three months or until
confirmation of placement.
21) Surgical Sterilization—Male

FDA approval: Not required.
Side effects and health risks: Men can experience pain, bleeding and
some infection from the surgery. “Considered permanent as reversal is
typically unsuccessful” (FDA 12/03).
Convenience: One-time surgical procedure.
22) Abstinence
FDA approval: NA
Side effects and health risks: None
Protection from STIs: Yes, as long as all forms of sex are abstained from.
Failure rate (births per one hundred women)a: None
Convenience: May be difficult to maintain long term.
Availability: Free. Does not require doctors or devices.
23) Withdrawal
FDA approval: NA
Side effects and health risks: May not withdraw in time. Pre-
ejaculate may contain viable sperm. Most practice withdrawal at each
sexual encounter.
Failure rate (births per one hundred women)a: Twenty-two
Convenience: Ineffective as birth control.
24) Breastfeeding
FDA approval: NA
Side effects and health risks: Takes time and energy. May lower vag-
inal lubrication during sex, which can cause pain.

Failure rate (births per one hundred women)a: Two
Convenience: Must breastfeed every four to five hours. Only works if
infant has a diet of only breast milk (not if infant also takes formula or
other foods as part of their diet). Can only be used as birth control for
the first six months of infant’s life or until menstruation returns, which-
ever comes first.
Source: From the “Birth Control Guide” (2018), Westheimer and
Lopater’s Human Sexuality (2002), Epigee Women’s Health, Fem-
inist Women’s Health Center, Planned Parenthood, “Answers to
Frequently Asked Questions About… How to Get Emergency Con-
traception” (2007), “Objections, Confusion Among Pharmacists
Threaten Access to Emergency Contraception” (2007), and American
Pregnancy Association.
Notes
a These statistics do not note the distinction between theoreti-
cal effectiveness rate and actual/use effectiveness rate. In se-
lecting a method of birth control, these distinctions should be
explored.
1 Projected from six-month study and adjusted for use of emergency
contraception.
2 If spermicides are used with barrier methods, be sure that the sper-
micide is compatible with the condom or diaphragm (will not cause
it to weaken or break). Oil-based lubricants (such as petroleum jelly
or baby oil) will cause latex to weaken and should not be used with
these methods.
3 Spermicides used alone, with barrier devices, or with condoms
can cause irritation to the skin lining of the vagina, especially
when the spermicide is used frequently. There is a possibility that
spermicide might increase the risk of acquiring some sexually
transmitted diseases because of rupture of the vaginal skin. Sper-
micide has not been proven to be effective against bacteria and
viruses in people. Therefore, there is no reason to use spermicide
during pregnancy.
4 Medications for vaginal yeast infections may decrease effectiveness
of spermicides.
5 Less effective for women who have had a baby because the birth
process stretches the vagina and cervix, making it more difficult to
achieve a proper fit.
In nonindustrialized societies availability of the methods described in Box
8.1 is expanding as a result of international family planning programs, govern-
ment programs, NGOs, and other organizational efforts. However, “traditional”
methods for birth control are still utilized in nonindustrialized societies among
ethnic, indigenous, and migrant populations and may coexist and/or be cultur-
ally fused with more traditional methods. For the sake of convenience and sim-
plicity we use the term “traditional” to refer to indigenous, ethnic, and cultural
practices prior to and coexistent with industrialized methods of birth control.
There are significant differences in the availability of industrialized methods
of birth control between rich and poor countries (Potts, 2003: 93). For instance:
• More than 200 million people throughout the world lack access to a full
range of family planning services (Planned Parenthood Global, 2019).
• More than 10 percent of married women around the world actively want
to use family planning but lack access to the contraceptives, information,
and services that would make that possible (World Family Planning High-
lights, 2017).
• Due to an increase in the number of women in their reproductive years,
the absolute number of women in need of family planning has increased
by 20 million between 2000 and 2020, (“World Family Planning High-
lights 2020,” 2020).
• The number of married or in-union women using contraception is pro-
jected to rise by 15 million globally, from 778 million in 2017 to 793 mil-
lion in 2030. The growth in the number of contraceptive users is projected
to be especially fast in Africa and Southern Asia. Globally, the number
of married or in-union women with an unmet need for family planning
is projected to decline slightly, from 142 million in 2017 to 130 million in
2030 (World Family Planning Highlights, 2017).
The United Nations reported on world contraceptive use in 2015 and has iden-
tified some distinct differences between industrialized and nonindustrialized na-
tions (note many agencies, organizations, and scholars use the term “developed”
and “developing nations”). Refer to Table 8.1. This information was collected
on contraceptive use by women between the ages of fifteen and forty-nine who
are married or in consensual unions. Selected trends from this research found:
• Sixty-four percent of married/in-union women of reproductive age in the

world are using contraceptive methods.
• In more industrialized nations that figure is above 70 percent; the pill is
most prevalent (22 percent) with the condom as second most common
(14 percent).
• In less industrialized nations that statistic is 53 percent; female steriliza-
tion is most prevalent (16 percent) with the pill as second most common
(9 percent) (“UN Trends in Contraceptive Use Worldwide 2015,” 2015).
Table 8.2 Health and economic indicators in countries with a high unmet need for
family planning
Country Gross national Maternal deaths Adult HIV Unmet need for
income per 100,000 live prevalence rate family planning (%);
per capita births in 2017 (%) in 2018 women ages 15–49
2018 (US$) (2005–2014)
Ghana $2,130 308 1.7 36

Haiti $800 480 2.0 35
Uganda $620 375 5.7 34
Benin $870 397 1.0 33
Liberia $600 661 1.3 31
Senegal $1,410 315 0.4 30
Guyana $4,760 169 1.4 28
Nepal $960 186 0.1 28
Ethiopia $790 401 1.0 26
Malawi $360 349 9.2 26
Mali $830 562 1.4 26
Sources: Compiled from “GNI per Capita” and “Prevalence of HIV,” World Bank, 2018; “UNICEF
Maternal Mortality Rates,” 2017; Sedgh et al., 2016, Guttmacher Institute.
While contraceptive use worldwide increased dramatically from 36 percent

in 1970 to 64 percent in 2015, the trends over the past fifteen years indicate
a more modest rise in contraception use overall in industrializing countries.
For example:
In Africa contraceptive usage among married/consensual union women in-
creased from around 25 percent in 2001 to 33 percent in 2015 (the most nota-
ble increase, but still the lowest usage globally); in Asia, from 66 to 68 percent;
Latin America and the Caribbean, from 69 to 73 percent. However, high levels
of unmet needs for family planning remain in the industrializing countries,
despite the growth in the use of contraception (“UN Trends in Contraceptive
Use Worldwide 2015,” 2015). The UN researches the trends and does an up-
date every year. The latest data is always available on their site. Also refer to
Table 8.2, “Health and economic indicators in countries with a high unmet
need for family planning” (Leahy, 2006).
The Alan Guttmacher Institute has summarized some important trends re-
garding contraceptive prevalence among 61 million women of child-bearing
age in the United States (“Fact Sheet: Contraceptive Use in the United
States,” 2018). Preferred birth control methods reflect an individual’s stage in
the life course, ethnic differences, and cultural milieu. Some of the important
findings excerpted from this research on US birth control are:
• The pill and female sterilization have remained the most prevalent meth-
ods since 1982.
• The pill is most preferred in younger women, never-married, and
college-educated women.
• Sterilization is most common among women over thirty-five, married, or
previously married, living below 150 percent of the federal poverty level,
and those without a college education.
• Sterilization is the leading method among black and Hispanic women,
while the pill is the leading method for white women.
• Fifty percent of all women aged forty to forty-four who practice contra-
ception have been sterilized (“National Survey of Family Growth,” 2017).
• Women in their teens and twenties are more likely to rely on the inject-
able method than are older women.
• Women aged twenty-five to twenty-nine are more likely than women in
other age groups to rely on the implant or IUD.
• Women who have used the injectable increased from 5 percent in 1995 to
23 percent in 2006–2010; the patch increased from less than 1 percent in
2002 to 10 percent in 2006–2010, and 6 percent had used the contracep-
tive ring in 2006–2010 (the first time it was included in surveys).
• 5.5 million women use barrier contraceptives, such as the male condom.
• Condom use is most prevalent among teenagers, twenty to twenty-four-
year-olds, childless women, and never-married women (“Fact Sheet: Con-
traceptive Use in the United States,” 2018).
In summary, availability and prevalence differs worldwide between more in-

dustrialized nations and less industrialized nations. Differing prevalence and
popularity is due to many factors: age; race; ethnicity; class; education; wom-
en’s status and gender inequity; and economic, political, religious, and other
cultural features that impact practices at the local, regional, national, and
global levels. Governments and special-interest groups may also seek to in-
fluence contraceptive choices. For instance, in the United States, the federal
government has spent over $2 billion in federal funding on abstinence-only
programs since 1996. According to a policy review by the Guttmacher Insti-
tute, proponents of these programs have co-opted public health and rights-
based language and rebranded abstinence-only policies such as “sexual risk
avoidance policies.” This language has typically been used for strategies
that address activities with inherent dangers, ones that outweigh any poten-
tial benefits, such as cigarette smoking or drunk driving. Regardless of the
name used, abstinence-only programs are ineffective in their goal of prevent-
ing pre-marital sex. The Guttmacher review also notes that these programs,
“withhold potentially life-saving information, promote dangerous gender ste-
reotypes, stigmatize sex, sexual health, and sexuality, and perpetuate systems
of inequity” (Boyer, 2018).
Contraceptive Methods Described

We will briefly describe the most well-known methods of contraception in
the United States. See Box 8.1, “Birth control methods guide,” as it offers a
summary of birth control options available in the United States as well as
in other industrialized/industrializing countries, although prevalence rates
differ as described earlier. For specific information on each world region see
Table 8.1. Where available, we include international data for the method un-
der discussion. In addition, keep in mind that new contraceptive choices and
government regulations are dynamic phenomena, thus new methods may be-
come available while this book is in the production and publication process.
Some of these methods of birth control are more effective than others. For
example, abstinence is effective in avoiding pregnancy provided one’s disci-
pline and determination are not challenged. Withdrawal (coitus interruptus)
where the male pulls out prior to ejaculation and douching are very ineffective
methods. Yet, 5 percent of the women in the more industrialized world prac-
tice this method and over 2 percent in the less industrialized nations. The fol-
lowing statistics indicate the prevalence of coitus interruptus among married/
consensual union women practicing contraception by country/region: Africa
(1 percent); Asia (3 percent); Europe (8 percent); Latin America and the Ca-
ribbean (3 percent); North America (4 percent); Australia and New Zealand
(2 percent); and Oceania (Melanesia, Micronesia, and Polynesia) (2 percent)
(figures are rounded to nearest percentage point, data from “UN Trends in
Contraceptive Use Worldwide 2015,” 2015).
Fertility awareness methods (FAMs) are based on keeping track of the
woman’s menstrual cycle to predict safe and unsafe days for coitus; during un-
safe days either abstinence or other methods should be used for sexually active
people. Worldwide data from married/consensual union women indicate the
percentages of people using the rhythm method by country and region are as
follows: Africa (2 percent); Asia (3 percent); Europe (2 percent); Latin Amer-
ica and the Caribbean (3 percent); North America (1 percent); Australia and
New Zealand (1 percent); and Oceania (Melanesia, Micronesia, and Polynesia)
(4 percent) (figures are rounded to nearest percentage point, data from “UN
Trends in Contraceptive Use Worldwide 2015,” 2015).
FAMs include: the calendrical method, the basal body temperature method,
and the Billings method (cervical mucous or ovulation method), along with
general efforts by women to keep records of their menstrual cycle. These rhythm
methods are based on identifying when a woman ovulates. There is a twenty-
four-hour fertility window that occurs immediately after ovulation in which the
woman’s egg can be fertilized. The calendar method is based on a formula in
which eighteen is subtracted from a woman’s shortest cycle and eleven from her
longest cycle observed over a minimum of eight cycles (day one is the start of
menstruation). This figure will represent the days that unprotected sex should
be avoided. Typical-use failure rates with this method are reported from 25 per-
cent to as high as 45 percent depending on the study (King, 2005: 148).
In the basal method, a woman takes her temperature daily upon rising and
charts when her temperature rises slightly over the course of her cycle. Within
twenty-four to seventy-two hours after ovulation, a woman’s temperature rises
by a few tenths of a degree. With this method, no intercourse should occur
from the end of menstruation until two to four days after her temperature rises.
According to King (2005), this method is a serious challenge to one’s will power
since it involves what can be perceived as a long period of abstinence, as does
the rhythm method. In addition, this technique requires a certain amount of
expertise in recognizing small temperature increases that may be due to causes
other than ovulation, such as illness. It has a typical-use failure rate of 75 per-
cent. The Billings method is based on the evaluation of vaginal mucous to
determine when ovulation takes place. Usually cloudy mucous becomes clear,
slippery, and stretchy one to two days prior to ovulation and then returns to its
cloudy form. Its typical-use failure rate has been reported as high as 80 percent.
The Billings method may be combined with the basal metabolic method to en-
hance the effectiveness of either technique (“Birth Control,” 2006; King, 2005).
Barrier methods include the male and female condom, the diaphragm, cer-
vical cap, and Leas’ shield. Barrier methods prevent pregnancy by placing a
barrier between the egg and sperm so that the sperm cannot reach the egg to
fertilize it.
The male condom is made of a variety of substances including latex rub-
ber, lamb intestine, polyurethane, or synthetic elastomers. The polyurethane
condoms are half the thickness of rubber condoms and offer enhanced sen-
sitivity and a more natural feel (King, 2005). The condom works by covering
the penis and containing ejaculated sperm. The male condom and the female
condom are effective against sexually transmitted infections, including HIV
(“Birth Control,” 2006; “Birth Control Guide,” 2003; Centers for Disease Con-
trol and Prevention, 2006). There are many advantages to the condom. Besides
its effectiveness in reduction of sexually transmitted infections and pregnancy
prevention, the male condom is easily available and may help with premature
ejaculation. The condom is the most frequently used method in some industrial-
ized nations including Japan, England, and some Northern European countries
(King, 2005). Worldwide data from married/consensual union women indicates
the percentages of people using condoms with their partners by country/region
are as follows: Africa (2 percent); Asia (8 percent); Europe (17 percent); Latin
America and the Caribbean (10 percent); North America (12 percent); Austra-
lia and New Zealand (14 percent); and Oceania (Melanesia, Micronesia, and
Polynesia) (2 percent) (figures are rounded to nearest percentage point, data
from “UN Trends in Contraceptive Use Worldwide 2015,” 2015).
The polyurethane female condom, FC1, was introduced by the Female
Health Company as a barrier method in the 1990s (“HIV Prevention Strat-
egy Highlights Women,” 1994: 26; Klugman, 1993: 70; “The Female Condom
FC2,” 2005). It offers women a method of pregnancy prevention with a 95 per-
cent success rate if used correctly and facilitates the prevention and transmis-
sion of HIV/AIDS and other STIs. Unfortunately, this product was expensive
to manufacture, seriously limiting its adoption in the international sector. It is
made of a seven-inch polyurethane bag held in place by two flexible rings. One
ring holds the condom against the cervix and the outer ring holds it in place
outside the vagina, partially covering the labia. It can be inserted up to eight
hours before intercourse. More recently, the Female Health Company has
developed FC2, a new version made of synthetic latex that is much cheaper
to produce. According to the World Health Organization, the lower cost may
lead to wider acceptance in international programs in preventing pregnancy
and STI/HIV transmission (“The Female Condom FC2,” 2005).
The female condom has certain advantages including offering women the
possibility of more control over STI/HIV and pregnancy, although the issue
of power inequities between men and women in the negotiation of sex is still
not resolved by this method. Its advantages are that it does offer women an
alternative with a partner resistant to condom usage and FC1 may be worn by
women with latex allergies. Users report that it feels more “natural” than sex
with male condoms and it may stimulate the clitoris providing women more
pleasure. Both the male and female condom may be put on or inserted as part
of sex play (“Birth Control,” 2006; “The Female Condom FC2,” 2005; “World
Contraceptive Use 2005,” 2005).
The diaphragm, a thin dome-shaped barrier that prevents sperm from en-
tering the cervix, is used with a spermicidal gel or cream. The diaphragm fits
snugly over the cervix and holds the spermicide in place. As a method of birth
control, the diaphragm is 86–94 percent effective. The disadvantages of the
diaphragm are that it does not protect against STIs/HIV. It may be inserted
up to two hours before intercourse (the effectiveness period of spermicide) and
additional spermicide must be inserted vaginally if more than two hours has
passed since insertion. It should not be removed for six to eight hours after in-
tercourse and additional spermicide must be used with every act of intercourse.
Its advantages are a high effectiveness in pregnancy prevention, ease of use,
comfort, and it does not affect the menstrual cycle. A diaphragm does require
a fitting by a healthcare professional. In the event of pregnancy and/or weight
change a refitting may be required. It has been found to cause allergic reactions
and may increase bladder infections (“Birth Control Comparisons,” 2006).
Additional barrier methods include the cervical cap, a much smaller bar-
rier than the diaphragm, also requiring the use of spermicide. Learning to
insert it may require practice and some technique, but it may be used for up
to forty-eight hours without reapplying spermicide. Another barrier method,
the sponge, is 90 percent effective when combined with a spermicide and can
be inserted up to twenty-four hours before penile-vaginal intercourse (“Birth
Control,” 2006). However, the FDA notes that the sponge is not currently
marketed in the United States due to concerns over an increased risk of toxic
shock syndrome. Lea’s Shield was approved by the FDA in 2002. It is a dome-
shaped rubber disk with a valve and a loop that is held in place by the vaginal
wall. It covers the upper vagina and cervix so that sperm cannot reach the
uterus. Spermicide is applied before insertion, but it provides no protection
against STIs/HIV. It can be inserted prior to intercourse and must be left
in place for at least eight hours (“Birth Control,” 2006; the “Birth Control
Guide,” 2003).
The barrier methods are designed to be used with spermicide. Since the
1950s, spermicides using nonoxynol-9, an agent that kills sperm, have been
available. Spermicide comes in various forms including foam, cream, jelly, film,
suppository, or tablet. Nonoxynol-9 does not provide protection against STIs,
including HIV/AIDS. It may actually increase the likelihood of STI/HIV in-
fection by irritating and causing lesions and exfoliation of the cellular lining in
the vagina and anus. Therefore, the World Health Organization and Centers
for Disease Control and Prevention recommend nonoxynol-9, preferably used
with a barrier method, for women who are at low risk for HIV transmission, but
it is not recommended for women at higher risk such as those who have vaginal
intercourse several times a day. Because nonoxynol-9 can damage the lining of
the rectum it should not be used as a lubricant for anal intercourse (Johnson
and Friedman, 2002). Worldwide data from married/consensual union women
practicing contraception aggregate the various vaginal barrier methods such
as diaphragm, cervical cap, sponge and spermicidal methods. The percent-
ages using vaginal barrier methods by country/region are as follows: Africa
(0 percent); Asia (less than 1 percent); Europe (1 percent); Latin America and
the Caribbean (less than 1 percent); North America (0 percent); Australia and
New Zealand (0 percent); and Oceania (Melanesia, Micronesia, and Polynesia)
(0 percent) (figures are rounded to nearest percentage point, data from “World
Contraceptive Use 2005,” 2005).
Hormonal methods offer several options for women. The oral contraceptive
pill (OCP) traditionally combines estrogen and progesterone to trick the body
into thinking it is pregnant and prevents the egg’s release. There are a variety
of kinds of OCPs on the market from the combination pill, those that include
both estrogen and progestin, to the mini pill. The mini pill contains only pro-
gesterone which inhibits the development of the uterine lining. In 2003, the US
Food and Drug Administration approved a new prescription drug called Ovcon
35, the first chewable (spearmint-flavored) oral contraceptive tablet for women.
Ovcon 35 contains a progestin (norethindrone) and an estrogen (ethinyl es-
tradiol) found in other OCPs that are already marketed. Another OCP is Sea-
sonale, approved by the FDA in 2003. This oral contraceptive pill containing
estrogen and progestin is taken in three-month cycles of twelve weeks followed
by one week of inactive pills. Women taking this OCP have their periods ev-
ery thirteenth week of the pill cycle. Consumers are attracted to having more
control over their cycles as well as providing contraceptive protection, although
no protection against HIV/STIs is provided. Other options include a class of
synthetic progesterone that includes norgestimate and desogestril, approved by
the FDA in 1993. These are similar to other OCPs, but with reduced side ef-
fects of weight gain, breast tenderness, acne, spotting, and nausea (Austin, 1993:
57). According to the National Cancer Institute, studies consistently show an
increased risk of breast cancer and cervical cancer in women who use OCPs,
and a decrease in endometrial, ovarian, and colorectal cancers (“Oral Contra-
ceptives and Cancer Risk,” 2018). There is also an increased risk of blood clots,
and cardiovascular health problems (heart attack and stroke) (Peck and Norris,
2012). This risk increases further for women who smoke cigarettes and take
OCPs, particularly if they are over the age of thirty-five (Peck and Norris, 2012).
Worldwide data from married/consensual union women indicate the per-
centages of people taking “the pill” by country/region are as follows: Africa (9
percent); Asia (6 percent); Europe (22 percent); Latin America and the Carib-
bean (15 percent); North America (16 percent); Australia and New Zealand
(29 percent); and Oceania (Melanesia, Micronesia, and Polynesia) (6 percent)
(figures are rounded to nearest percentage point, data from “UN Trends in
Contraceptive Use Worldwide 2015,” 2015).
Emergency contraception comes in several forms of OCPs. These include
an OCP referred to as “the morning-after pill” in its early days, but later con-
ceived as post-coital contraceptive or emergency contraception (EC). Typical
protocol for EC consists of two doses of an oral combination contraceptive
pill that contains a synthetic estrogen (ethinyl estradiol) and levonorgestrel.
If taken within five days after intercourse, the effectiveness rate in preventing
pregnancy is up to 95 percent (the sooner the EC is taken after unprotected
sex, the higher the effectiveness) (“Emergency Contraception,” World Health
Organization, 2018). It has no effect on an established pregnancy and operates
to prevent ovulation, fertilization and possibly implantation of a fertilized egg
(“Get in the Know: 20 Questions about Pregnancy, Contraception and Abor-
tion,” 2006; King, 2005).
Plan B offers another hormonal option for emergency contraception. Plan B
is a progestin-only pill taken in two doses twelve hours apart or the two doses
may be taken at the same time. It is more effective than the combination pill
offering 99.5 percent effectiveness within twenty-four hours of intercourse and
85 percent effectiveness if taken within three days (“Birth Control,” 2006;
“Birth Control Guide,” 2003; King, 2005). On August 24, 2006, the FDA ap-
proved over-the-counter sale of Plan B to women eighteen years of age and
older. According to Planned Parenthood (2006), particular birth control pills
may be used in the same way and for the same end; the dosage varies by brand/
type of pill. A third method of emergency contraception is implantation of an
IUD. It is 99 percent effective if inserted within five days of unprotected sex
(“Emergency Contraception: How to Take,” 2006).
The National Women’s Health Network states:
There is no scientific or medical reason for the eighteen and older age re-
striction that the FDA has imposed on obtaining non-prescription Plan B.
Studies show that increased access to EC does not cause teen promiscuity or
other health risk behaviors. And top FDA officials have privately acknowl-
edged that the age restriction is a political concession to conservative activ-
ists who have been fighting to keep barriers to contraception access in place.
(“Plan B: One Step Forward, Two Steps Back,” 2006)
Other methods of delivery of hormonal contraception include the patch (Or-

tho Evra), approved in 2001. The patch contains estrogen and progestin that
is applied once a week for three weeks to the upper body, lower abdomen,
or buttocks. During the fourth week it is removed and menstruation occurs.
Implants under the skin are another way to deliver hormonal birth control.
Norplant is a three-inch-long delivery system that is placed under the skin
of the arm. Easily implanted, but more difficult to remove, Norplant releases
progestin and provides protection against pregnancy for five years at a 99 per-
cent efficiency rate. However in 2002, as a result of lawsuits due to problems in
removal and side effects, the makers of Norplant announced they were halting
manufacture of their product and women should find other options after the
five-year expiration (“FDA Approves Long-Term, Implantable Birth Control,”
2006; Findlay, 1991: 126; Klugman, 1993: 70; Sivin et al., 1983).
Similar to Norplant are several other types of implants that deliver hor-
mones. Implanon recently became available in the United States in 2006.
Implanon is a small rod about 1.5 inches long that is injected under the skin
(requiring a local anesthetic) of the upper arm. It is 99 percent effective and
provides protection for up to three years through the delivery of a progestin
that prevents ovulation, thickening the cervical mucous to interfere with fer-
tilization by the sperm and altering the lining of the uterus to prevent implan-
tation (“Birth Control,” 2006). Implanon has been sold in over thirty countries
since 1998 (“FDA Approves Long-Term, Implantable Birth Control,” 2006).
Jadelle, a two-rod levonorgestrel contraceptive implant was FDA-approved in
1996, but has not been sold in the United States. It may provide protection for
up to five years and is currently available in industrializing and industrialized
nations (“Jadelle Implants: General Information,” 2005).
In 1992, the FDA approved the hormonal method, Depo-Provera. An in-
jectable synthetic progesterone, Depo-Provera prevents the release of ova and
interferes with the implantation of the egg in the uterus lining. One injection
works for three months with a 99 percent effectiveness rate. A new formula-
tion of Depo-Provera was approved by the FDA in 2005, “Depo-SubQ Pro-
vera 104.” This is delivered by subcutaneous injection four times a year (every
twelve to fourteen weeks). Lunelle, a once- a-month shot, is no longer available
in the United States (“Birth Control Guide,” 2003).
Worldwide data from married/in-union women practicing contraception indi-
cates the percentages of people using injectable or implant hormone methods by
country/region are as follows: Africa (12 percent); Asia (4 percent); Europe (less
than 1 percent); Latin America and the Caribbean (7 percent); North America
(1 percent); Australia and New Zealand (5 percent); and Oceania (Melanesia,
Micronesia, and Polynesia) (11 percent) (figures rounded to nearest percentage
point, data from “UN Trends in Contraceptive Use Worldwide 2015,” 2015).
Introduced in 2001, the vaginal contraceptive ring (NuvaRing), a flexible
ring that releases estrogen and progestin, is worn for three weeks and removed
for one week. The downside of this method is that if the ring has been expelled
for more than three hours, another method of birth control must be used.
The intrauterine device (IUD), a small metal or plastic device placed in
the uterus, was popular in the 1960s and 1970s in the United States. Un-
fortunately, subsequent medical follow-up revealed negative side effects and
health risks. These included an association between some IUDs and Pelvic
Inflammatory Disease as well as other health problems including infertility.
One consequence of this research was that the Dalkon Shield was taken off
the market. Despite this, the IUD remains the most predominant reversible
method of birth control practiced in the world today (“IUD,” 2006). IUDs
prevent sperm from uniting with an egg and/or may alter the lining of the
uterus to prevent implantation. Several kinds of IUDs are currently avail-
able. IUDs are small plastic inserts made with either copper or progesterone.
ParaGard is a copper IUD that may be left in place for up to twelve years,
and Mirena is a progesterone hormone IUD that may be left in place for five
years. As previously mentioned, according to Planned Parenthood Federation
of America, ParaGard may also be used as emergency contraception and is 99.9
percent effective if inserted within five days of unprotected sex (“Emergency
Contraception: How to Take,” 2006). Worldwide data from married/in-union
women indicates the percentages of those using an IUD by country/region are
as follows: Africa (4 percent); Asia (17 percent); Europe (11 percent); Latin
America and the Caribbean (6 percent); North America (5 percent); Australia
and New Zealand (2 percent); and Oceania (Melanesia, Micronesia, and Poly-
nesia) (less than 1 percent) (figures rounded to nearest percentage point, data
from “UN Trends in Contraceptive Use Worldwide 2015,” 2015).
In the early 1990s, the World Health Organization studied testosterone en-
anthate (TE) injections as a form of hormonal contraception in 271 men in
seven countries. The weekly injections had few side effects and a success rate
of 99.2 percent, which made it more effective than OCPs (91 percent) and
condoms (82 percent), and as effective as IUDs (99.2–99.8 percent) (Center for
Disease Control and Prevention 2011). After four months of weekly testoster-
one injections, a man’s level of sperm was reduced enough to have a contracep-
tive effect. This was reversible after six-and-a-half months (“Men’s Shots Used
as Contraceptive,” 1990; Prendergast, 1990). A 2006 review of clinical trials by
Peter Liu and associates (2006) verified that testosterone hormone treatment
can temporarily stop sperm production. Dr. Peter Liu and his research team
analyzed thirty trials conducted from 1990 to 2005 that included more than
1,500 men, and confirmed the findings of the earlier WHO study of testoster-
one that this method appears to be effective, reversible (sperm levels returned
to normal within about three to five months after stopping the treatment) and
with few side effects (“A Contraceptive Pill for Men,” 2006; “Male Contracep-
tive Reversible,” 2006). Subsequent studies, however, suggest testosterone is
not as reliable a contraceptive as initially indicated, with some studies showing
successful sperm reduction as low as 64 percent in some cases (Patel et al.,
2019). In addition, one recent study ended prematurely due to higher than
anticipated adverse side effects, such as depression, increased libido, acne, and
weight gain (Patel et al., 2019). To date, the US Food and Drug Administration
has not approved testosterone for contraceptive use (Patel et al., 2019). The
Population Council is researching MENT, a synthetic steroid similar to testos-
terone that holds promise as a method to suppress sperm production without
enlarging the prostate (Kumar et al., 2006).
Other approaches to lower sperm counts couple testosterone and progestin.
Because progestin reduces testosterone production and hence sperm produc-
tion, researchers have administered low doses of testosterone in conjunction
with various kinds of progestins. Trials using oral progestin or progestin im-
plants, combined with various types of testosterone injections and/or a patch
were analyzed with the preliminary finding that the progestin implant plus
testosterone injection was the most effective approach in suppressing sperm
production (Anderson et al., 2002; Christensen, 2000; Gonzalo et al., 2002).
Other methods to control births include surgical procedures for sterilization.
The vasectomy interferes with sperm ejaculation by surgically cutting or cau-
terizing the vas deferens through a procedure that involves small incisions in
the scrotum under local anesthetic. This typically takes about twenty minutes
in the doctor’s office. The no-scalpel technique is an alternative method in-
vented and widely used in China and subsequently in the United States since
1985. It involves puncturing the skin with a special instrument, followed by
severing or blocking vas deferens. The benefits of this method are that only
one cut is made without the need for stitches and recovery is faster than in
the conventional method (“No-Scalpel Vasectomy,” 2006). In 2003, Vasclip
was introduced in the United States. This technique uses a very small plastic
clamp (the size of a grain of rice) that is snapped onto the vas deferens to block
sperm through a micro-surgical procedure. Vasclip is less painful than the tra-
ditional vasectomy and reversing the procedure is also easier. Ejaculation still
occurs with the various vasectomy techniques since the majority of fluid comes
from the prostate and seminal vesicles. Although doctors are improving their
success rates in reversing vasectomies, with some reporting up to a 50 percent
success rate, vasectomy should be regarded as a nonreversible and permanent
method of sterilization. Success rates depend on a number of variables includ-
ing the type of vasectomy and length of time passed (“Birth Control Guide,”
2003; King, 2005; Kirby, Utz, and Parks, 2006).
Sterilization methods for women include tubal ligation, a surgical procedure
that involves cutting, cauterizing, banding, or tying the fallopian tubes. This
may be accomplished with a very small incision either through the abdomen
or through the navel. This technique known as a laparoscopy includes inser-
tion of a scope/tube through the navel to view and perform the tubal ligation.
The unfertilized egg is subsequently absorbed by the body. The failure rate
is less than one in one hundred pregnancies (“Birth Control Guide,” 2003).
The Essure method was approved by the US Food and Drug Administration
in 2002. In this technique, a tiny insert shaped like a spring is placed in each
tube, which irritates the tubal lining causing it to form scar tissue and resulting
in the obstruction of the fallopian tubes and passage of the egg. In contrast
to tubal ligation, the Essure method is a nonsurgical procedure done through
the vagina. The down time is low and the woman can return to work/regular
routines within twenty-four hours. Currently success in reversing female ster-
ilization is still limited (“Birth Control Guide,” 2003; Ubeda, Labastida, and
Dexeus, 2004).
Worldwide data from married/in-union women and men practicing birth
control indicate the percentages of people using female sterilization by coun-
try/region are as follows: Africa (less than 2 percent); Asia (24 percent); Europe
(4 percent); Latin America and the Caribbean (26 percent); North America
(21 percent); Australia and New Zealand (6 percent); and Oceania (Melane-
sia, Micronesia, and Polynesia) (11 percent). The percentages of those using
male sterilization by country/region are as follows: Africa (0 percent); Asia (2
percent); Europe (3 percent); Latin America and the Caribbean (3 percent);
North America (12 percent); Australia and New Zealand (9 percent); and
Oceania (Melanesia, Micronesia, and Polynesia) (less than 1 percent) (figures
rounded to nearest percentage point, data from “UN Trends in Contracep-
tive Use Worldwide 2015,” 2015). The gender differences in sterilization are in
some cases very dramatic and are anchored in gendered cultures, ideologies of
reproductive responsibility, and power inequities.
Abortion
Contemporary methods of abortion include surgical abortions and medical
abortions. Generally, medical problems arising from abortions are few if con-
ducted by trained professionals in hygienic environments; less than 1 percent
of all abortions in United States incur complications. The risk of death due
to abortion is less than one-tenth as large as the risk of childbirth; roughly
less than 0.6 per 100,000 procedures. Furthermore, abortions do not increase
a woman’s future health risk for other pregnancies and there is no increased
incidence of infertility, miscarriages, tubal, or cervical pregnancies or breast
cancer (“Abortion,” 2006; Waxman, 2004). In countries where abortions are
illegal, 47,000 women a year die from complications, and many more have
their health compromised by unsafe conditions (“Safe and Unsafe Induced
Abortion: Global and Regional Levels in 2008, and Trends During 1995–
2008,” 2012).
The majority of abortions, about 90 percent, occur during the first trimester,
with 56 percent prior to the eighth week (“Abortion,” 2006; “Get in the Know:
20 Questions about Pregnancy, Contraception and Abortion,” 2006; “Who
Gets Abortions” 1990: G1). The vacuum aspiration method is the most com-
mon first trimester technique. This method involves the insertion of a tube
into the cervix. The tube is attached to a hand-held device or a suction ma-
chine that withdraws the endometrial tissues from the uterus. In the manual
vacuum aspiration method (MVA), the tissues from the uterus are gently suc-
tioned through a hand-held device. This method may be used as early as three
weeks and up to approximately seven weeks after the last menstrual period.
Between six and twelve weeks, the machine suction procedure is preferred.
For these first trimester pregnancies later than six weeks, local anesthetic and
dilation of the cervix is performed along with suction. Dilation of the cervix
may include insertion of an absorbent material the evening before which en-
hances the stretching of the cervix. As with the dilation and evacuation (D
and E) procedure (discussed as follows), medication and/or the use of dilation
rods may also be incorporated. In addition to either the MVA or machine
suction, the use of a curette to further evacuate the uterine walls may also be
used if suction alone was not enough (referred to as dilation and curettage or
D and C); although this approach is seldom used during the first trimester but
somewhat later (weeks twelve to fifteen). The benefit of the vacuum aspiration
method is that it takes only ten minutes and is done on an outpatient basis
under a local anesthetic requiring only a few hours of recuperation in a clinic
(“Abortion,” 2006; Goldberg et al., 2004; Hyde, 1985: 266).
Second trimester abortion rates drop dramatically with only 10 percent oc-
curring during this period with the most prevalent method that of dilation and
evacuation (D and E) (“D&E Abortion Bans: The Implications of Banning
the Most Common Second-Trimester Procedure,” 2017; “Second-Trimester
Abortions Concentrated Among Certain Groups of Women,” 2011). Dila-
tion and evacuation combines the vacuum aspiration method with elements
of dilation and curettage (D and C). D and E may include the insertion of
an absorbent material that dilates the cervix. The dilation material is usually
inserted the night before the procedure is performed to facilitate the absor-
bent material in gradually stretching open the cervix. Medications used either
alone or in conjunction with dilators (rodlike devices) may also be incorpo-
rated. During the D and E, the patient is sedated or given IV medication as
well as numbed locally; the dilator material is removed followed by evacuation
of the uterus using suction and medical instruments (such as the curette) to
clean the uterine walls further. The procedure takes between ten and twenty
minutes. Dilation and evacuation is the preferred method for second trimester
abortions (weeks thirteen to twenty-four) and even third trimester abortions
because of the safety, efficacy, and time efficiency involved in this procedure.
Only about 1 percent of late-term abortions occur after the twentieth week
with less than one-tenth of 1 percent occurring at the twenty-fourth week and
then only if the mother’s health is at risk (“Abortion,” 2006; Westheimer and
Lopater, 2005).
Another but infrequently used option for late-term pregnancy termination
is the induction method. This method is seldom used and only when there
is a severe medical problem in the mother or fetus during the latter part of
the second trimester or into the third trimester. Medications are injected into
the amniotic sac and the vagina to cause contractions and the expulsion of the
nonliving embryonic tissues; these medications include prostglandin, saline
and/or other substances (“Abortion,” 2006; “Planned Parenthood,” 2006).
Hormonal methods of abortion, also referred to as medication abortions,
are another choice for women but currently are limited to the first trimester of
pregnancy. One type of medication uses the drug mifepristone (Mifeprex) as
an abortificant. It is known more popularly in the United States as RU 486.
This method is effective in the first two months of pregnancy and is 95–97
percent successful if used with misoprostol, a prostglandin. This protocol was
tested on 2,000 women in the United States in the fall of 1994 (American
Health, 1994: 8). Mifepristone works by inducing menstruation and prevent-
ing implantation in women who suspect fertilization by interfering with the
production of progesterone and causing the lining of the uterus to slough. A
second medication, misoprostol, is taken three days following mifepristone
causing the cervix to soften and the uterus to contract thereby prompting a
miscarriage in the early stages of gestation (“Abortion,” 2006; Dowie, 1991:
137–140; Hall, 1989: 44; “Historical Information on Mifepristone,” 2006; King,
2005; Klugman, 1993: 59).
Mifepristone was originally produced by a French company and accepted
for use in 1988. It was not approved in the United States until 2000 amidst
substantial controversy. It is authorized by the federal Food and Drug Admin-
istration to terminate pregnancy up to forty-nine days after the last menstrual
cycle. Other countries have adopted it although not without controversy; the
United Kingdom and Sweden approved it in 1991, Germany in 1992 and other
European countries by 1999. Currently it is available in approximately sixty
countries and it has been proven safe with few adverse reactions and compli-
cations (“Questions and Answers on Mifeprex,” US Food and Drug Adminis-
tration, 2019). However, some research indicates it has more side effects than a
surgical abortion, although 90 percent of the women in one study stated they
would opt for it again (Jones and Henshaw, 2002; “RU 486 Non-Surgical/Med-
ical Abortion,” 2006). In France it is used in about one-third of the abortions.
Figures for the United States indicate it is increasingly used, from 5 percent
of the abortions in 2001 to 24 percent in 2004 (“Get in the Know: Medi-
cation Abortion, 2006). Anti-abortion advocates are against the legal use of
mifepristone (“Historical Information on Mifepristone,” 2006). Mifepristone is
relatively fast acting and produces a medical abortion within a week in 92 per-
cent of the cases with 95–97 percent effectiveness within two weeks. The side
effects include cramping, bleeding, and clotting (“Abortion,” 2006; “Abortion
Information,” 2006).
Methotrexate is another drug commonly used in the United States that pro-
duces the same effect as mifepristone; it is followed by misoprostol about five
days later. Methotrexate is an injection that inhibits reproductive growth and
can be used up to the ninth week of gestation. It is FDA approved but is used
off label as an abortificant and is effective 90–97 percent of the time (“Abor-
tion,” 2006; Westheimer and Lopater, 2005). With methotrexate/misoprostol,
approximately 75 percent of the abortions are completed within a week, but in
15–20 percent of the women it can take up to four weeks (“Abortion,” 2006;
“Abortion Information,” 2006).
In the United States abortion is a hotly debated issue framed in diverse terms
such as choice, life, personhood, and reproductive rights reflecting heteroge-
neous scholarly, religious, political, biological, and philosophical perspectives.
The cultural meaning surrounding birth control methods such as abortion
have varied considerably through time and across cultures. Worldwide and
throughout history women everywhere have always been interested in hav-
ing some control over their reproductive lives, whether it was to ensure and
manage fertility, space births, or control the number of births and offspring.
A cultural constructionist perspective will allow us to better understand this
current controversy. Cross-culturally and historically there is considerable
variation regarding when a blastocyst, embryo, fetus, neonate, or infant has
been socially recognized as human and achieved personhood (Morgan, 1996).
The anti-abortion camps in the United States have focused on creating “fetal
personhood” and hence fetal rights (i.e., to life). Those sectors that support
a woman’s right to choose whether to terminate a pregnancy focus on wom-
en’s reproductive rights, and their sexual and reproductive autonomy. Cross-
culturally the possible approaches to defining humanity and personhood are
much further-reaching than the perspectives currently taken in the United
States (Morgan, 1996). Notions of abortions and fetal personhood are related
to wider socio-cultural patterns including the status of women, social stratifica-
tion, gender ideologies, beliefs about the life cycle and bodies, mythology, the
sacred world, and other features of social life including the family and kinship
(Morgan, 1996; Ward and Edelstein, 2006).
For an example of how abortion is embedded in the socio-cultural matrix,
we need look no further than our own history. Before the nineteenth century,
it was a woman’s decision regarding termination of a pregnancy that was made
up to the time of the quickening, when she first felt fetal movements, at about
four months of pregnancy. Abortificants (drugs for abortions) were widely ad-
vertised and available; reflecting the pre-nineteenth-century belief that life
began when the child moved, not at conception (Crandon, 1986: 471). “In
1800 there was not, so far as is known, a single statute in the United States
concerning abortion” (“Abortion in American History,” 1990: 8). However,
over the next one hundred years abortion became illegal in every state, with
the only exception allowed if the woman’s life was endangered. This may be
partially attributed to the efforts of the newly formed American Medical As-
sociation’s desire to legitimize and co-opt the maternal/female body as territory
that had previously been under the control of women and midwives. Accord-
ing to the medical view, only physicians were sufficiently informed to know
when abortions were necessary and justified (Crandon, 1986: 471). Until the
1960s, women were excluded from equal entry into medical schools, thereby
ensuring that women had no voice in this issue until Roe v. Wade (“Abortion
in American History,” 1990: 8).
The controversy surrounding abortion in the United States is represented
by two dominant perspectives: Pro Choice and Pro Life. The Right-to-Life
(Pro-Life) position argues that the blastocyst/embryo/fetus is a human life
from the moment of conception and has the right to life regardless of the
health risk, societal bias, and personal cost to the woman. The Pro-Choice
position believes that the woman has the right to autonomy over her repro-
duction and that women’s reproductive rights should prevail. In 1973 in the
landmark case of Roe v. Wade, the US Supreme Court, ruled seven to two that
a woman could decide (with her physician) to terminate a pregnancy in the first
trimester and that the state could not interfere with that right. The judgment
also allowed for second trimester abortions (Renzetti and Curran, 2003). Ironi-
cally, the Roe v. Wade decision set a standard for future government interest in
the rights of the fetus during the third trimester (Lacayo, 1990: 23). Although
Roe v. Wade has been held up by the Supreme Court in various challenges,
anti-choice supporters have been successful in putting limits on access to abor-
tion for some women, especially teenage, poor, and rural women at the state
level. For example, in July 1989, the Supreme Court ruled in favor of Webster
v. Reproductive Health Services. A Missouri law allowed states to deny Med-
icaid funds for abortions as well as facilities for abortion and required doctors
to test for fetal viability at twenty weeks (potential of fetus to survive outside
the women’s body). The decision paved the way for states to pass laws limiting
and restricting abortions in a variety of other ways (Carlson, 1990: 16; March
E-News, 2006; Renzetti and Curran, 2003).
The election of President Bill Clinton and a Democratic pro-choice plat-
form subsequently resulted in greater government support of the Roe v. Wade
decision. However, Clinton’s successor, George W. Bush, voiced his opposition
to abortion and passed legislation to undermine Roe v. Wade in several ways.
This included a global gag rule that denied funding to any international agen-
cies that provided information on abortion or abortion services. This presi-
dential mandate was first implemented by Ronald Reagan (1984), endorsed
by George Bush (I), subsequently overturned by Clinton (1993), and then re-
instated by the George W. Bush administration in 2001 on the anniversary of
Roe v. Wade. Since George W. Bush, other legislation has followed whose goal
is to undermine Roe v. Wade and to create a culture supporting fetal person-
hood over the reproductive rights of the woman. This legislation is backed by
far-right fundamentalist Christian leaders, their followers, and conservative
legislators who seek the support of this constituency. Anti-choice legislation in
some states has sought to limit women’s access to abortion by requiring coun-
seling, waiting periods prior to abortion, parental permission, and parental no-
tification before abortion can be performed. These laws are regarded as part of
a political strategy to lay the groundwork for restricting women’s reproductive
freedom and eventually overturning Roe v. Wade. While these tactics do limit
the number of abortions in a given state, the abortion rates of adjacent states
increase (“An Overview of Abortion in the United States,” 2003). In 2003,
George W. Bush proposed the “Partial Birth Abortion Ban” to outlaw proce-
dures as early as twelve to fifteen weeks of pregnancy. Federal judges ruled the
law unconstitutional (Harrison, 2004).
At the end of the Obama presidency (2009–2017), CNN reported that the
abortion rate in the United States had reached its lowest level since the Roe v.
Wade decision in 1973 (Siemaszko, 2017). This decline was at least in part due
to fewer unintended pregnancies (“Abortion Incidence and Service Availabil-
ity in the United States, 2014,” Guttmacher Institute, 2017). President Barack
Obama supported the Roe v. Wade decision and women’s right and freedom to
make decisions about their own bodies and health (The White House Office
of the Press Secretary, 2016). As a result, he ended the ban on federal funds
for international groups that perform or provide information about abortions
Table 8.3 Laws and abortion policies by statea as of November 2019
Law or policy State
Parental notification Colorado, Delaware,b Florida, Georgia, Illinois, Iowa,

required with minors Maryland,b Minnesota,c New Hampshire, Oklahoma, South
Dakota, Texas, Utah, Virginia, West Virginia,b Wyoming
Parental consent Alabama, Arizona, Arkansas, Idaho, Indiana, Kansas,
required with minors Kentucky, Louisiana, Massachusetts, Michigan, Mississippic,
Missouri, Nebraska, North Carolina, North Dakotac, Ohio,
Oklahoma, Pennsylvania, Rhode Island, South Carolina,d
Tennessee, Texas, Utah, Virginia, Wisconsina, Wyoming
Mandatory counseling Alabama, Alaska, Arizona, Arkansas, Connecticut, Florida,
Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana,
Maine, Massachusetts, Michigan, Minnesota, Mississippi,
Missouri, Montana, Nebraska, Nevada, North Carolina,
North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode
Island, South Carolina, South Dakota, Tennessee, Texas,
Utah, Virginia, West Virginia, Wisconsin
Mandatory wait Alabama, Arizona, Arkansas, Georgia, Idaho, Indiana, Kansas,
Kentucky, Louisiana, Michigan, Minnesota, Mississippi,
Missouri, Nebraska, North Carolina, North Dakota, Ohio,
Oklahoma, Pennsylvania, South Carolina, South Dakota,
Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin
Physician-only Alabama, Alaska, Arizona, Arkansas, Delaware, Florida,
restriction: certain Georgia, Hawaii, Idaho, Indiana, Iowa, Kansas, Kentucky,
qualified health Louisiana, Maryland, Massachusetts, Michigan, Minnesota,
professionals Mississippi, Missouri, Nebraska, Nevada, New Jersey,
restricted from New Mexico, New York, North Carolina, North Dakota,
performing abortions Ohio, Oklahoma, Pennsylvania, Rhode Island, South
Carolina, South Dakota, Tennessee, Texas, Utah, Virginia,
Washington, Wisconsin, Wyoming
Refusal: certain Alaska, Arizona, Arkansas, California, Connecticut, Delaware,
individuals or entities Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas,
can refuse to provide Kentucky, Louisiana, Maine, Maryland, Massachusetts,
reproductive health Michigan, Minnesota, Mississippi, Missouri, Montana,
services, information, Nebraska, Nevada, New Jersey, New Mexico, North Carolina,
or referrals North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode
Island, South Carolina, South Dakota, Tennessee, Texas, Utah,
Virginia, Washington, Wisconsin, Wyoming
Freedom of Choice Act California, Connecticut, Hawaii, Maine, Maryland, Nevada,
in state law Washington
State funding of Alabama, Arkansas, Colorado, Delaware, District of Columbia,
abortion under Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky,
Medicaid in cases of Louisiana, Michigan, Mississippi, Missouri, Nebraska,
life endangerment, Nevada, New Hampshire, North Carolina, North Dakota,
rape, and incest Ohio, Oklahoma, Pennsylvania, Rhode Island, South
Carolina, Tennessee, Texas, Utah, Virginia, West Virginia,
Wisconsin, Wyoming
Information excerpted from: ProChoice America, https://www.prochoiceamerica.org/wp-con-

tent/uploads/2017/04/2015-Who-Decides.pdf.
a Supreme Court on April 18, 2007, by a five to four ruling upheld the ban on partial-birth
abortion. The impact this will have on the states is still to be determined.
b Specified health professionals able to waive parental involvement if judge is involved.
c Both parents must be involved.
d Minor laws in Delaware apply to women under sixteen, and minor laws in South Carolina
apply to women under seventeen.
(New York Times, February 3, 2009). While Obama supported women’s right to
choose, his administration’s efforts were challenged in several states. In 2010,
Obama signed the Patient Protection and Affordable Care Act into law.
The new law required states to establish state-level healthcare exchanges to
assist individuals and small businesses with purchasing private health plans.
Several states preemptively enacted laws that restrict abortion access in pri-
vate health insurance policies purchased through the exchange (in addition
to abortion bans already in existence in the insurance policies of public
employees) (“Restricting Insurance Coverage of Abortion,” Guttmacher In-
stitute, 2019).
After Donald Trump became President in 2017, women’s rights were again
under increased attack. Although Trump was pro-choice up until running for
President, he subsequently vowed to do everything he could to overturn Roe v.
Wade (Scheindlin, 2019). In that effort, he appointed judges to federal courts
who are committed to overturn Roe v. Wade; he reshaped the Supreme Court
with his ultra-conservative appointments of justices; and he emboldened state
legislatures to pass increasingly restrictive abortion legislation (Scheindlin,
2019). Trump also ordered a global gag rule, which prohibited
US-supported
international family planning groups from using their own money to provide
safe and legal abortions, or even to provide information on where to get a safe
abortion (Center for Reproductive Rights, 2017). In 2019, Trump also issued a
domestic Title X gag rule, severely limiting low-income, underinsured, and un-
insured individuals’ access to reproductive healthcare services in the United
States (Center for Reproductive Rights, 2019).
The reproductive freedom of women in the United States, and elsewhere for
that matter, is far from established. Continued vigilance is required to main-
tain and affirm women’s reproductive rights. For information on state policies
on abortion, see Table 8.3. For the most recent information summarizing state
policies on abortion, see the Alan Guttmacher Institute website at www.gutt-
macher.org/sections/abortion.php.
Efforts to undermine Roe v. Wade have galvanized the pro-choice support-
ers and activists favoring women’s reproductive rights. Not only was this repre-
sented in the 2006 mid-term elections and in three states voting for legislation
to protect abortion rights, but it is represented in numerous policy statements
by diverse professional organizations, non-profit organizations, family plan-
ning agencies, religious organizations, and various citizen groups. According
to a 2018 Gallup poll of US adults, approximately 60 percent support abortion
rights in the first three months of pregnancy (Saad, 2018). Only 28 percent,
however, think abortion should be legal in the second trimester, and that num-
ber drops to 13 percent for abortions in the last three months of pregnancy. In
addition, the results of this poll show that:
• Support for abortion per trimester is equal for men and women, but dif-
fers by age, education, and party affiliation, with young adults, college-
educated adults, and Democrats being more supportive.
• Eighty-three percent think abortion should be legal in the first trimester
if the mother’s life is at risk, and 77 percent approve if the pregnancy was
caused by rape or incest.
• Twenty-five percent are against abortion in the third trimester even if the
mother’s life is at risk.
• Sixty-seven percent support abortion in the first trimester if the child’s life
is at risk (48 percent in the third trimester).
• Fifty-six percent support abortion in the first trimester if the child would
be born mentally disabled (35 percent in the third trimester).
• Forty-five percent support abortion in the first trimester when the woman
does not want the child for any reason (20 percent in the third trimester).
(“Trimesters Still Key to U.S. Abortion Views,” 2018)
A 2019 Pew Research Center report corroborates the Gallup poll numbers. It
notes that 61 percent of US adults support legal abortion in all or most cases,
and 31 percent say it should be illegal in all or most cases (“Public Opinion
on Abortion” 2019). Considerable research substantiates that most Americans
do not want Roe v. Wade overturned (“About seven-in-ten Americans oppose
overturning Roe v. Wade,” 2017; de Pinto, 2019).
Abortion: Trends and Practices in the United States and

Industrialized Nations
To discuss abortion and other birth control methods in the United States, in-
ternationally and cross-culturally (emphasizing indigenous populations) requires
that we maintain a culturally relativistic stance. Though abortion is certainly
not the most desired practice in family planning, for some women it may be
their only opportunity to have control over their reproduction. According to the
Guttmacher-Lance Commission, globally about 56 million women have abor-
tions each year, with 25 million of them surreptitious, illegal, and conducted
under unsafe conditions. Close to 90 percent of all abortions occur in the in-
dustrializing nations. In the United States, about 6 million women become
pregnant annually, with about half of all the pregnancies unintended (about 3
million), and about half of the unintended pregnancies end in abortion (“Accel-
erate Progress–Sexual and Reproductive Health and Rights for All,” 2018; “Un-
intended Pregnancy in the United States,” 2019). As we discussed in Chapter
11, US teenagers have the highest pregnancy, childbearing, and abortion rates
among the industrialized nations. The reason for this is that they use contracep-
tives less than do teens in other industrialized nations. Socio-economic status
(class) is a variable associated with abortion that must be considered. Despite
the decline in abortions in the United States generally, abortion has increased
among poor women. Race and ethnicity are also factors in abortion rates. The
Guttmacher Institute notes that lack of health insurance and health care, as
well as racism and discrimination impact these numbers (“Abortion rates con-
tinue to vary by race and ethnicity,” 2017). Consequently, black non-Hispanic
Table 8.4 Reported abortions, by known weeks of gestation, age group, race, and
ethnicity of women who obtained abortions—selected reporting areas,
United States, 2015.
Characteristic Weeks of gestation
≤8 9–13 14–17 ≥18
No. (%) No. (%) No. (%) No. (%)
Age group (yrs)a,b

<15 441 39.0 416 36.8 76 6.8 60 5.4
15–19 23,096 56.7 12,644 31.0 1,505 3.7 987 2.4
20–24 83,216 63.5 35,597 27.2 3,953 3.0 2,140 1.6
25–29 77,945 67.0 28,969 24.9 3,056 2.6 1,664 1.4
30–34 51,351 68.4 17,720 23.6 1,842 2.4 1,160 1.6
35–39 29,596 68.9 9,863 23.0 1,096 2.6 647 1.5
>40 10,790 70.5 3,285 21.5 371 2.4 245 1.6
Totalb 276,435 65.4 108,494 25.7 11,900 2.8 6,903 1.6
Race/Ethnicitya,c
White 82,889 67.7 29,683 24.2 3,056 2.5 1,880 1.5
Black 70,937 59.1 36,360 30.3 3,982 3.3 2,350 2.0
Other 20,448 70.3 6,252 21.5 742 2.6 462 1.6
Hispanic 42,110 67.5 14,970 24.0 1,704 2.8 944 1.5
Total 216,384 64.8 87,265 26.1 9,484 2.8 5,635 1.7
Source: Tara C. Jatlaoui et al., “Abortion Surveillance—United States, 2015,” 2018.

a Row percentages might not add to one hundred because of rounding.
b Data from thirty-nine reporting areas; excludes thirteen reporting areas (California, Con-
necticut, District of Columbia, Florida, Illinois, Kentucky, Maryland, Massachusetts, New
Hampshire, New York State, Pennsylvania, Wisconsin, and Wyoming) that did not report,
did not report weeks of gestation by age, or did not meet reporting standards.
c Data from twenty-eight reporting areas; excludes twenty-four reporting areas (California,
Connecticut, District of Columbia, Florida, Illinois, Iowa, Kentucky, Louisiana, Maine,
Maryland, Massachusetts, Mississippi, Nebraska, New Hampshire, New Mexico, New York
State, North Carolina, North Dakota, Oklahoma, Pennsylvania, Rhode Island, Washington,
Wisconsin, and Wyoming) that did not report, did not report weeks of gestation by age, or did
not meet reporting standards.
women have an abortion rate of 27.1 per 1,000 women, followed by Hispanic
women at 18.1, non-Hispanic Others at 16.3, and non-Hispanic whites at 10.0
(Jones and Jerman, 2017). See Table 8.4. How do women feel about having an
abortion? Research has found that the majority of women feel a huge sense of
relief, and are not, in fact, traumatized by the experience. Although many may
experience ambivalence, sadness, and guilt in their decision making, research
shows that 95 percent of women who have had an abortion felt it was the right
decision when asked three years later (Rocca et al., 2013). Women who did ex-
perience psychological problems afterward were likely to have had emotional
problems prior to the abortion (“Abortion and Mental Health,” American
Psychological Association, 2019; Steinberg et al., 2014). There is no scientific
evidence that having an abortion leads to psychological/emotional disorders.
In fact, Gilligan (1982) argues:
By studying abortion decisions and their consequences, we may come to

see the whole process of making a decision to have an abortion (or to have
the baby and give it up for adoption, or to keep the baby) as fostering psy-
chological development and growth, at least if handled well. Women may
emerge from the process being more mature and having better-developed
moral sensitivities.
(cited in Hyde, 1985: 268)
Abortion rates are higher in countries where it is illegal. See Table 8.5. Ward and
Edelstein propose that women “will do anything” to have control over fertility
and childbearing—even pursue an illegal abortion (2006). That they will pursue
abortions under unsafe and illegal conditions testifies to the anguish women feel
in having an unintended pregnancy. In fact, science shows that women who are
denied abortion are more likely to experience psychological distress than women
who receive an abortion (“Abortion and Mental Health,” 2019; Rocca et al., 2014).
Table 8.5 Examples

of legal trends in international abortion
Liberal access Very restricted or Increased restrictions Liberalized since

prohibited since 1995 1995
Belgium Afghanistan El Salvador Albania

Cambodia Bangladesh Hungary Australia
Canada Bhutan Poland Benin
China Brazil The Russian Federation Burkina Faso
Cuba Brunei United Statesa Cambodia
Denmark Central Africa Chad
France Republic Colombiaa
Germany Chile Ethiopia
Greece Colombiaa France
Hungary El Salvador Guinea
The Netherlands Guatemala Mali
Norway Indonesia Mexicoa
Portugal Ireland Nepal
Sweden Iran South Africa
Switzerland Iraq Switzerland
Ukraine Mexicoa
United Statesa Nigeria
Vietnam Sudan
Tanzania
Uganda
Venezuela
Source: Boonstra et al., 2006, “Abortion in the United States Today”, “Global Illegal Abortion:
Where There Is No ‘Roe’,” Planned Parenthood; “The World’s Abortion Laws,” Center for Re-
productive Rights.
a Although abortion law reform may expand or reduce access to abortion, this may not impact
the classification of the country’s status as liberal or restricted.
Getting accurate statistics on abortions, both legal and illegal, is not an

easy task. Where abortions are legal and where there are few restrictions,
accurate data can be collected. However, where it is illegal or restric-
tive, data must be collected by other methods than government reports
and accuracy is therefore somewhat questionable (Henshaw, Singh, and
Haas, 1999).
Abortion: A Focus on Industrial Nations

The lowest abortion rates occur in western European countries where abortion
is legal, covered by national health insurance, and where unintended pregnancy
rates are low. Eight industrialized countries with complete data have rates be-
low 10 per 1,000–all of them in Europe except for Singapore, namely: Belgium,
Finland, the Netherlands, Singapore, Slovakia, Slovenia, Spain and Switzer-
land (“Abortion Worldwide 2017: Uneven Progress and Unequal Access,” 2018).
Countries in which abortion is legal tend to be industrial nations; where it is
illegal, the countries tend to be industrializing/nonindustrialized nations.
• In 61 countries (where 37 percent of women of reproductive age live) abor-

tions are legal.
• In 125 countries (where 42 percent of women of reproductive age live)
abortions are highly restricted (either illegal or only permitted to save the
woman’s life). Twenty-six countries prohibit abortion without exception.
• In Europe, 41 out of every 1,000 pregnancies in women ages 15–44 are
unintended (compared to 62 out of every 1,000 pregnancies globally). Out
of these, 29 end in abortion (compared to 35 globally).
• Although Eastern Europe has seen a significant decline in abortion rates,
the region still has the highest abortion rate in Europe with 42 percent of
pregnancies ending in abortion.
• In the former Soviet Union, and the nations of former Yugoslavia, abor-
tion has been legal since the 1950s.
• Broadening the legal grounds for abortion lowers maternal mortality rate.
For instance, in Romania, maternal mortality rate dropped from 148
death per 100,000 live births in 1989 to 9 per 100,000 live births in 2002,
after restrictions on abortions were lifted.
• Abortion rates in Western Europe are at a low of 16 abortions per 1,000
women (“Abortion Worldwide 2017: Uneven Progress and Unequal Ac-
cess,” 2018).
Aside from Eastern Europe, Ireland is also a special case in our discussion of
illegal abortion in industrialized nations. Up until 2018, Ireland banned abor-
tion except when the mother’s life was endangered. Abortion was first made
illegal in 1861, and in 1983 a constitutional amendment was passed granting
the fetus the right to life, meaning it had equal right to life as the mother.
The consequences of this were that between 1980 and 2004 at least 117,673
(Irish) women traveled to Great Britain to have abortions, with estimates of
approximately 6,000 a year. Other findings suggest that Irish women may have
traveled to other European Union countries where abortions were less expen-
sive than in England (“Abortion Law in Ireland: A Brief History,” 2006; “Irish
Abortion Statistics,” 2006; “Submissions of the Irish Family Planning Asso-
ciation to the UN Committee on the Elimination of Discrimination Against
Women,” 2005). In 2018, the Irish repealed the eighth Amendment to the
Irish Constitution (the right-to-life amendment) in a referendum, with a land-
slide 66 percent of voters rejecting the amendment. As of January 1, 2019,
abortion is legal in Ireland up to twelve weeks of pregnancy (after a three-day
waiting period), as well as in cases where the mother’s life or health are at risk,
and in cases of fatal fetal anomalies (“History of Abortion in Ireland,” Irish
Family Planning Association, 2018).
Several trends emerge from this discussion of abortion. High rates of abor-
tion are found in countries where women lack information and access to
controlling reproduction; in many countries, women lack the personal and
political power to implement family planning strategies as well. Low abortion
rates, such as occur in the Netherlands, are correlated with widespread acces-
sibility to comprehensive sexuality education. Although it is important for the
world’s women to have the option of abortion as one strategy to limit unin-
tended pregnancies and provide them with autonomy over their reproductive
choices, it would be preferable for women to have affordable and effective birth
control rather than the more medically intrusive abortion.
A Focus on Industrializing/Nonindustrialized Nations

One report argues that the availability of family planning services in indus-
trializing nations can reduce abortions by 75 percent. According to Sonefield
(2006: n.p.): “beyond their medical impact, family planning programs also have
far-reaching social, economic and psychological benefits for women, families
and nations.” However, abortion remains an important option for women who
find themselves with an undesired pregnancy regardless of their motives for
termination. Many of the women who seek abortions in countries where it is
illegal are married with children that they cannot support. In 2017, the Trump
administration instituted a Global Gag Rule that prohibited international
family-planning groups that received financial support from the US from us-
ing those funds to provide safe and legal abortions, or referrals or information
on where to get abortions, placing women’s lives and health at risk (Center for
Reproductive Rights, 2017). Without the availability of contraceptive informa-
tion and the option of a legal abortion, women with undesired pregnancies are
compelled to seek illegal and unsafe methods. Unsafe abortions are the major
cause of maternal death in the industrializing/nonindustrial nations where it
is illegal. Research reveals:
• Twenty-five million abortions are carried out annually in unsafe

conditions.
• Twenty-two thousand deaths are attributed to illegal unsafe and unhy-
gienic abortions.
• One in twelve maternal deaths is due to an unsafe abortion.
• Asia, Africa, and Latin America account for the highest numbers of
women seeking unsafe abortions (97 percent of all unsafe abortions)
(“Abortion Worldwide 2017: Uneven Progress and Unequal Access,” 2018;
“Unsafe abortion: a forgotten emergency,” 2019).
Grimes et al. (2006) refer to the international scope of unsafe abortion as “the
preventable pandemic,” which can be mitigated by legal, safe, and accessible
abortion. They attribute “[t]he underlying causes of this global pandemic [to]
apathy and disdain for women; they suffer and die because they are not valued”
(2006: 1).
Many industrializing countries have access to modern methods of am-

niocentesis and sonograms to detect fetus abnormalities, but in China,
India, Bangladesh, Pakistan, and Indonesia, these technologies are used
to select male fetuses and abort the female fetuses (“Asia: Discarding
Daughters,” 1990: 40; Ward and Edelstein, 2006). According to Ward
and Edelstein (2006: 231): these are the “disappeared and endangered
daughters” represented in countries where gender inequity leads to
excess mortality and asymmetrical gender ratios in births. For exam-
ple, in India, 110 male infants are born for every 100 female infants
(“Gender-biased sex selection,” 2018). Such an imbalance can have far-
reaching consequences in terms of adult marriage patterns. China’s pol-
icy of one child per couple, encouraged by severe financial sanctioning,
has resulted in the continued practice of female infanticide and am-
niocentesis to identify and then abort female fetuses. In a society that
historically favored males, females were considered an economic liability
(Burton, 1990: 36; Ward and Edelstein, 2006).
Traditional Methods of Birth Control in Cross-Cultural

Context
We shall now shift our emphasis to indigenous and cross-cultural methods for
birth control. As discussed earlier, it is important to remember that for many
in nonindustrialized nations, traditional methods also co-exist with mod-
ern methods. This is also true of industrialized nations with indigenous and
immigrant populations. The importance of culture in shaping the practices
and meanings of birth control is illustrated by Marvin Harris (1989: 210) when
he asserts:
Sex does not guarantee conception; conception does not lead relentlessly
to birth; and birth does not compel the mother to nurse and protect the
newborn. Cultures have evolved learned techniques and practices that
can prevent each step in this process from occurring.
In our discussion of the cross-cultural context for birth control, we will empha-
size ethnographic research both classic and contemporary. This spans a wide
timeframe including research on indigenous societies prior to contact with
colonizing countries, post contact, and contemporary indigenous and ethnic
communities within a global context, at various points in time. Methods of
birth control have a long history and tremendous variety since people have
been interfering with reproduction prior to the invention of twentieth/twenty-
first-century methods like the pill, although methods like IUDs certainly have
their antecedents. Earlier we discussed birth control in industrializing nations.
Here we focus on preindustrial and indigenous peoples. It is important that we
approach this subject with the lens of cultural relativism because some of the
methods used to control fertility and births, manage birth spacing and popula-
tion include methods that challenge industrial ideologies, beliefs, and values,
such as infanticide and abortion.
In this regard, the terminology “traditional methods” needs explication.
Various industrialized national and international organizations such as the
United Nations and researchers who study fertility, birth, and population con-
trol define traditional methods as “non-technological and less effective than
more recently invented methods such as the oral contraceptive pill” (Hirsch
and Nathanson, 2001: 413). This dichotomy represents an etic approach and
not one necessarily used emically (Hirsch and Nathanson, 2001). Moreover,
the notion that some of the traditional methods are “ineffective” has been
challenged by research on various contraceptive herbs, as well as the predeces-
sors to modern methods such as IUDs and abortificants. With this caveat in
mind, we use the term “traditional” method for convenience and to emphasize
preindustrial practices to avoid impregnation, control birth spacing, births,
and offspring. However, this does not mean that women have not engaged in
practices that were not only ineffective; for example, Plains Indians wore a
contraceptive charm known as a “snake-girdle” made of beaded leather over
the navel (Gregersen, 1983: 291), but some were also dangerous. In this regard,
Ward and Edelstein (2006: 77) note: “It is clear from all the ethnographic and
historic accounts we have that human desire for controlling the life stream is
universal; it transcends time and space.” Much of the knowledge and practices
for controlling fertility, number of births, and birth spacing is women’s secret
and sacred knowledge, shared by networks of women and passed on through
generations. The lengths women will go to control their fertility have been
and are extraordinary; prior to Roe v. Wade, US women exposed themselves to
infection and even death in order to have illegal abortions, as many do today
in countries where abortion is illegal. As noted earlier, Ward and Edelstein
(2006: 81) refer to this as the “women will do anything” principle in order to
have control of their reproductive lives.
Worldwide traditional methods are still practiced in industrialized, indus-
trializing and nonindustrialized countries. The United Nations defines tradi-
tional methods as including prolonged abstinence, breast feeding (lactational
amenorrhea), douching, and various other folk methods. The data aggregated
by country/region for use of traditional methods are as follows: Africa (2
percent); Asia (less than 1 percent); Europe (1 percent); Latin America and
the Caribbean (1 percent); North America (1 percent); Australia and New
Zealand (0 percent); and Oceania (Melanesia, Micronesia, and Polynesia) (3
percent) (figures rounded to nearest percentage point, data from “UN Trends
in Contraceptive Use Worldwide 2015,” 2015).
However, indigenous and pre-industrial methods include a far wider array
than that defined by the United Nations as “traditional” or “folk” methods.
For example, coitus interruptus is the predominant method found cross-
culturally (Gregersen, 1994; Harris, 1989), but it is not defined by the UN as
an indigenous or folk method since it is also used by modern industrialized
and industrializing people, including US teenagers. (See earlier discussion for
worldwide statistics on this usage in more industrialized and less industrialized
countries.) As noted earlier, this method’s effectiveness is limited, with 25 out
of 100 women using this technique conceiving within a year (King, 2005).
Cross-cultural examples illustrate how cultural meanings define and permeate
this practice. For example, in East Bay, a Southwest Pacific people studied by
William Davenport, abstinence from marital coitus was the preferred method
for controlling birth spacing, while coitus interruptus was the technique used
in extramarital relationships (Davenport, 1977).
The cross-cultural and historical records reveal numerous other ethno-
theories and practices. Various indigenous peoples use techniques to expel
the semen after intercourse with ejaculation; for example, the Kavirondo
and Zande rely on body movement such as standing and shaking after inter-
course (Gregersen, 1994: 83, 290–291). This is not unlike the sexual folklore
among some college students that standing up immediately after sex reduces
the chance of conception. Other approaches have emphasized the avoidance
of intercourse and timing of intercourse through the use of postpartum sex
taboos that last from two to five years. Alternatives to intercourse with ejac-
ulation have included mutual masturbation and “outercourse” methods that
avoid vaginal penetration (Ward and Edelstein, 2006).
Historical and cross-cultural research reports an abundance of contraceptive
and abortificant recipes of herbs, medicines, and potions used by the ancient
Greeks, Romans, Egyptians, and other preindustrial and indigenous peoples,
past and present (Kroeber, 1953: 248; Riddle, Estes, and Russell, 1994: 29–35;
Schneider, 1968: 365; Ward and Edelstein, 2006). For example, the demand for
Silphium, a plant in the parsley family, which was widely used by the Greeks
as a contraceptive and abortificant from the seventh century BC to the fourth
century AD, contributed to its extinction. The ancient and cross-cultural
record reveals a variety of herbs that inhibited conception and terminated
pregnancy including Queen Anne’s Lace, pennyroyal, willow, date palm,
pomegranate, and acacia gum. The effectiveness of the chemical properties
of these herbs in affecting fertility has been clinically demonstrated (Riddle,
Estes, and Russell, 1994: 29–35). According to Ward and Edelstein (2006: 78):
Recipes over the last seven thousand years recommend a wide variety of
oily, astringent, acidic, gummy or fibrous substances, alone or in combi-
nation. The bark and nuts of many kinds of trees provide tannic acid,
an astringent vegetable compound that is a remarkably effective spermi-
cide. Vinegar or ascetic acid, yogurt, honey, salt, butter and buttermilk
are also reported from China, India or the Middle East. The [women] of
history made tampons or contraceptive suppositories out of lint, cotton,
wool, silk, seaweed, or other common household fibers and absorbent sub-
stances. Any household spermicide could be used with a tampon or as a
douche for washing out the vagina. These were relatively effective and
easily available.
Modern sponges, barrier methods, and IUDs have their antecedents as well.
Women have placed various barriers against the cervix including beeswax, lard,
and tissues made of bamboo. IUDs were made of buttons, stone, and gems placed
in a woman’s uterus. Sponges soaked in spermicides such as lemon juice and
then placed against the cervix are one of the oldest and most effective methods.
As mentioned earlier, a diverse array of oral abortificants, recipes for contra-
ception and sterility were part of women’s culture (Ward and Edelstein, 2006).
In addition to these methods, women’s desire to control their reproduction
included other approaches and interventions such as abortion and infanticide.
In a cross-cultural study of preindustrial societies, George Devereux found that
464 groups practiced abortion (1967: 92–152). A variety of techniques was used
for abortion. Oral recipes for abortificants and emmenagogues challenge in-
dustrial emic and etic distinctions between encouraging a menstrual cycle to
occur and an abortion. An emmenagogue is a recipe that causes menstruation,
and in the process, it may include the termination of an early pregnancy by
inducing a miscarriage (Ward and Edelstein, 2006: 271). In this regard, Ward
and Edelstein assert: “Historic and ethnographic accounts make no sharp
distinction between contraception and abortion” (2006: 79). Cultures may
openly condone or condemn such forms of managing reproduction. Women
are placed in conflicted situations in those societies that simultaneously pre-
vent contraception and abortion.
Infanticide in which a neonate is allowed to die or is purposely killed has
primarily occurred in situations where survival of parents or the group is at
stake as in cases with overpopulation, or in times of scarce resources such
as famine. It also is found in indigenous cultures with strong gender prefer-
ences for males (see Chagnon, 1983; Divale and Harris, 1976; Harris, 1993;
Yanomamo discussed in greater depth). Morgan’s (1996) research has found
that it is also distinctly tied to cultural notions of humanness and personhood.
For example, on Truk, abnormal or deformed newborns were not defined as
human but rather as ghosts; they were burned or thrown into the sea. To the
Trukese a ghost was not a human and was not a person, therefore it could not
be actually killed. In such societies, neonates are not presumed to be born hu-
man, but must be conferred with humanity based on certain physical charac-
teristics. Once humanity is designated, then cultural ideologies of personhood
can come into play. For many societies, personhood is a process and an attri-
bute that is acquired and socially recognized. In the United States personhood
is not just ascribed at birth but has become part of a political and religious
philosophy that is accorded to fertilized eggs, blastocysts, embryos, and fetuses
(Morgan, 1996).
Preindustrial and indigenous women have employed a number of tech-
niques to engage in the control of births and reproduction. As discussed ear-
lier in this chapter, attitudes, beliefs, and birth control practices including
abortion are related to subsistence, economic, political, social, historical,
and religious factors among others. These are also linked to the gender sys-
tem including women’s status and power. We shall discuss several examples
highlighting the interrelationship of culture including ideologies, features of
social organization, and culture change to methods used for controlling re-
production. For example, how people make a living and methods of fertility/
birth control are interrelated. With plant cultivation, horticulture, and agri-
culture, population growth has occurred over the last 10,000 years. This has
resulted in an escalating system of sedentism; surplus; complexity of social
organization (ranking and hierarchy); centralization of authority; unequal
access to prestige, power, and resources; and the loss of status for women.
These features are related to issues of birth spacing, beliefs about family size,
the value of children to the household economy, and gender preferences for
children. There is a complex relationship between culture and the social sys-
tem that impacts birth control beliefs and practices. We shall offer three case
studies illustrating the biocultural basis for understanding the complex rela-
tionship of culture, reproduction, population, and social organization. Three
case studies – the Ju/wasi, the Yapese, and the Yanomamo – are used to illus-
trate these intersections.
Ju/wasi
Foragers (gatherers and hunters) are excellent examples of how culture shapes
biology in relation to population. One widely accepted anthropological theory
correlates sedentism (i.e., permanent residence due to plant cultivation) with
population expansion. This line of reasoning is supported by data from across
the ethnographic spectrum and includes evidence from the Ju/wasi (formerly
known as !Kung, or San, also known as Ju/’hoansi) peoples of the Kalahari
Desert (Robbins, 2006). The settlement of Ju/wasi into permanent villages
has provided evidence of the effects of sedentism on a previously foraging
population and, together with other lines of evidence, contributes to under-
standing the impact of sedentism on populations prehistorically/historically,
offering insight into environmental adaptation and demographics (Bates and
Fratkin, 2003).
The Ju/wasi, like tropical foragers in general, are known for small popula-
tions. A number of interacting factors are believed to contribute to this situ-
ation. Foragers have diets low in fat and high in protein, and, consequently,
they have less body fat than food cultivators. The critical fat theory (Frisch,
1978: 22–30) argues that fertility can be reduced in several ways by the low
body fat levels; most notably through adolescent sterility (introduced in Chap-
ter 11) and through the practice of extended lactation without supplemental
food sources. In order to ovulate, women need a certain amount of body fat,
minimally estimated at 15 percent. Body fat levels are influenced by extended
lactation which requires a great deal of caloric energy, and this combined with
a foraging lifestyle, keeps fertility and reproduction low among gatherers and
hunters. In contrast, plant cultivators, especially agriculturalists, can gener-
ate a large surplus of calories. Sedentism along with the increased calories
encourages higher body fat levels in women, counteracts trends for adoles-
cent sterility seen among foragers, and results in increased fertility and repro-
duction (i.e., population expansion associated with food producers especially
agriculturalists).
The critical level of fat storage necessary for menstruation and ovulation to
occur is about 150,000 stored calories of energy, enough “to permit a woman to
lactate for one year or more without having to increase her prepregnancy ca-
loric intake” (Lancaster, 1985:18). A period of subfertility for several years after
menarche exists among some foragers, but this declines in settled populations.
According to Lancaster (1985: 18): “Sedentism combined with high levels of
caloric intake leads to early deposition of body fat in young girls and ‘fools’ the
body into early biological maturation long before cognitive and social maturity
are reached.”
Foragers typically have other cultural practices that contribute to smaller
populations. One method is birth spacing (Ember, Ember, and Peregrine,
2005). Foragers who may roam over vast territory cannot afford to nurse and
carry more than one child who has not yet achieved the ability to walk compe-
tently. The Ju/wasi for example, have solved this dilemma by spacing children
about four years apart. Several cultural practices contribute to Ju/wasi birth
spacing. One of these is a long postpartum sex taboo that requires abstinence
from coitus for a minimum of a year. Foragers are well-known for long post-
partum sex taboos for women as a way to space and indirectly control births.
A correlation exists between societies that have long postpartum sex taboos
and those with low fertility rates (Ember, Ember, and Peregrine, 2005; Nag,
1962: 79).
Foragers with low body fat ratios can interrupt ovulation by prolonged nurs-
ing, which in turn contributes to keeping body fat levels low. “It is now well
established that the longer a mother nurses her baby without supplementary
foods, the longer the mother is unlikely to start ovulating again” (Ember, Em-
ber, and Peregrine, 2005: 168). Ju/wasi mothers nurse for two or three years
without the additional sources of food available to settled agriculturalists and
industrialists such as milk from domesticated animals or harvested grain. Lac-
tating females, in populations where body fat is low, are less likely to become
pregnant because ovulation is depressed (Ember, Ember, and Peregrine, 2005;
Kottak, 1991: 203).
Two other techniques that are used by foragers to control births are infanti-
cide and abortion. Hunters and gatherers practice abortion and are known for
their knowledge of pharmacology in which animal and plant poisons are used
to cause the fetus to miscarry (Gregersen, 1983: 291). Procedures include the
use of herbal treatments and toxic substances from animals, vigorously hitting
or manipulating the stomach through massage or squeezing, and having some-
one jump on the abdomen (Devereux, 1955; Gregersen, 1983: 290–291; Riddle
et al., 1994: 29–35; Sarvis and Rodman, 1974; Ward and Edelstein, 2006). In
addition, Devereux (1955) and Sarvis and Rodman (1974) report attempts to
abort the fetus through strenuous activity or through the use of devices or sub-
stances that are inserted into the uterus. These techniques may cause harm to
the mother and are dangerous but show the lengths that women will go to for
control of their reproductive lives (Ward and Edelstein, 2006).
Yapese
With regard to methods of abortion, David M. Schneider’s (1968: 383–406)
report and analysis of abortion on Yap, a Caroline Island in Micronesia, is a
classic ethnographic example of how beliefs, political economy, gender rela-
tions, and demographics intersect. Yap is an island that once supported 50,000
people. Yet, by 1945, the population had fallen dramatically to only 2,500. The
culture was one that was geared to a much larger population; consequently,
the population decline affected socio-political organization in that there were
no longer enough people to fill positions and perform necessary political func-
tions and services. This resulted in a generalized Yapese concern and desire for
more children. In spite of this, women continued the practice of self-abortions.
Self-induced abortions on Yap have, in fact, exacerbated the depopulation
problem since these also tended to occur “during the maximum years of fe-
cundity” (Schneider, 1968: 384). However, abortion may not have been the
sole cause of the continued depopulation of Yap as gonorrhea or possibly some
other diseases have undoubtedly contributed to the low fertility rate.
Given this situation, it is not surprising that self-induced abortion on Yap
was negatively sanctioned and kept secret, especially from the men. Because
abortions were objected to on moral grounds, Yapese women were under pres-
sure to remain secretive, lest they become known as aborters, which could
jeopardize their marriages or chances for marriage since men want and desire
children. To understand the perpetuation of abortion practices by women in
spite of depopulation, it is necessary to engage in a holistic analysis of Yapese
culture (i.e., one that considers all aspects of Yapese life). There were three
methods of self-induced abortions on Yap. According to Schneider (1968: 385):
One [method] consists in a series of magical manipulations with little ap-

parent efficacy… The other two techniques are empirically more effective.
One of these is drinking boiled concentrated sea water. Women described
the effect as a general feeling of illness accompanied by vomiting and
severe cramps.
The other technique consists in introducing a thin rolled plug of hibis-
cus leaves (which expand when moist) into the mouth of the cervix and
then injuring and scratching the mouth of the cervix with a bit of stick,
stone, iron, fingernail, or other sharp object until blood is drawn. Women
informants generally agreed that injuring the area about the mouth of the
cervix was necessary in addition to inserting the plug….
The latter method can lead to infection and associated reproductive problems,
although medical reports suggest that the resulting infection is mild and not
life threatening.
Historically, Yapese population decline may be traced back to a period when
population had peaked. What is remarkable about this situation is that, de-
spite the serious depopulation that followed, Yap culture in its traditional form
has continued as an adaptation to a dense population; this is an example of
culture lag. Abortion was a part of this earlier adaptation and represented an
effective solution to an overpopulation problem at the time. However, the per-
sistence of abortion in the face of decline in population must be understood
in the context of the totality of the culture, including gender relations and
expectations. Abortion was tied directly to gender role expectations for Yapese
women over the life course.
Women up to the age of thirty do not want children because they would
no longer be free to fall in and out of love, to attract lovers, to have and
break off affairs at will, to practice the elaborate games of love and socia-
bility that appeal to young Yap men and women. They do not want to be
tied to a child and to a husband when they are in the best position to gain
and enjoy the rewards of being unattached … On Yap the standard and
available means of avoiding children is to induce abortion when preg-
nancy occurs.
(Schneider, 1968: 393)
After the age of thirty, however, women’s attitudes began to change and
the desire for children was accelerated. This coincides with the transition
from youth to adult status. In summary, abortion persisted on Yap in spite of
population decline because the period of youth was regarded as a time when
women have access to the rewards and pleasures of love affairs in a system in
which they will never achieve the prestige positions and rankings available
to men.
Infanticide cross-culturally also illustrates the complexity and necessity
for a holistic perspective in understanding birth control. This should not be
construed to mean that infanticide has not been practiced in industrialized
societies as a method of regulating unwanted births. It has! Historically, Eu-
ropeans favored indirect methods of infanticide such as overlaying (where a
mother “accidentally” suffocated her child by rolling over on it when in bed);
wet nurses whose reputations for infant care literally guaranteed that the child
would die; or foundling homes such as those in France between 1824 and 1833
where 336,297 children were abandoned. “Between 80 percent and 90 percent
of the children in these institutions died during their first year of life” (Harris,
1989: 214).
Infanticide as a method to control birth is found in a variety of forms around
the globe. It includes the indirect methods just discussed that are favored by
the Europeans and others such as the northeast Brazilians (Scheper-Hughes,
1992), or may include conscious systematic neglect, starvation, and/or environ-
mental exposure as more direct approaches. In many contexts and for many
reasons both personal and cultural (e.g., poverty, the desire to limit family size,
and gender preferences, among others), surreptitious infanticide may be the
only solution for the mother with an unwanted pregnancy (Harris, 1989: 211).
Reports of direct infanticide in non-technologically complex societies suggest
that between 53 percent and 76 percent of these societies allow for the practice
of this method. In such situations, the cultural conception of being a person,
a member of the family and the group is not given to newborns (Harris, 1989:
212, 214).
Yanomamo
Marvin Harris’s (1974, 1993) re-analysis of Napoleon Chagnon’s study of the
Yanomamo of Venezuela and Brazil is a classic work that illustrates how in-
fanticide relates to warfare and a male supremacy complex among tribal cul-
tivators. The Yanomamo represent a case study supporting a broader theory
by Divale and Harris (1976) whose cross-cultural correlational study of the
HRAF files proposes that warfare is the most common way for tribal culti-
vators to regulate populations. This happens in an indirect way through the
practice of female infanticide, rather than directly by male deaths due to war.
The thesis behind their argument is that in order for population size to be
controlled, the limiting factor must be females and not males. The idea behind
this is that one male can impregnate a number of females; therefore, societies
can afford to lose adult males without affecting their population. Warfare and
conflict encourage a strong preference for male children because they can be
raised into strong and aggressive warriors (Robbins, 2006).
At the time of Chagnon’s original research, the Yanomamo were a tribal
society of 15,000 living in 125 villages (Chagnon, 1983). They were originally
riverine Indians whose ancestors were pushed into a forest adaptation due to
population pressure and colonization. These Yanomamo became skilled hunt-
ers and engaged in shifting cultivation in the forest. About 400 years ago they
began cultivating plantains and as a result of this semi-sedentary existence
combined with additional calories supplied by the plantains, they experienced
a rapid population growth spurt. Eighty-five percent of the Yanomamo diet
was from the plantains and the bananas that they cultivated. This feature is
a central part of Harris’s (1993; and Divale and Harris, 1976) argument. In-
creased calories and sedentism offset natural mechanisms for birth spacing and
low population that we have seen operating in gatherers and hunters such as
the Ju/wasi. Plant cultivation, which provides more carbohydrates and higher
caloric intake than foraging, allows for earlier puberty, increased conception,
and generally a longer childbearing period.
According to Harris’s (1993) argument, shifting cultivation did not meet
Yanomamo needs for protein. As they became semi-settled cultivators, their
high carbohydrate diet and increased population led them to put increasing
pressure on the local game resources for protein. Anthropologist Brian Fer-
guson’s (2001) study of Yanomamo warfare adds some nuances to Harris’s the-
ory although they are generally on the same page in terms of the Yanomamo
preferences for males and the development of a male supremacy complex and
its role in female infanticide. Ferguson (2001) argues that the real impetus for
the Yanomamo warfare and aggression was the availability of Euro-American
manufactured goods in the 1950s and 1960s. For Ferguson, this is what led to
the creation of permanent settlements as Yanomamo founded anchor villages
near trading outposts. The establishment of these more permanent villages is
what Ferguson believes led to the depletion of game.
Both Harris and Ferguson agree that the development of a male supremacy
complex occurred in order to help create fiercer hunters and warriors in re-
sponse to the dwindling game. In addition, the growing populations who set-
tled in villages came into conflict over protein as a scarce resource which also
contributed to and escalated warfare. According to Ferguson, fierce aggressive
males were needed to protect and acquire manufactured goods as well. This
complex of warfare, hunting, and competition for manufactured goods placed
a premium on males, rather than females. In the history of the world, it is rare
for women to participate in warfare since this would make poor evolutionary
sense. The premium on males ultimately led to female infanticide as a method
for parents to select for sons over daughters. The Yanomamo preferred that
the firstborn was a son and practiced infanticide if a girl was the firstborn. Be-
cause Yanomamo females did not fight, hunt, and bring home the protein, they
were valued less than males. Female infanticide contributed to a population
inequity in the ratio of male to females; there were 449 males to 391 females
in seven villages studied by Chagnon (1983). This gender inequity perpetu-
ated fighting and raiding to acquire women from other villages which, in turn
escalated the warfare even further. The Yanomamo practiced polygyny so that
the best fighters and hunters could acquire several wives through the lure of
protein, rank, and prestige. Twenty-five percent of the men were polygynous.
This added fuel to the fire by creating an even greater shortage of women. In
this situation warfare operated as a way to disperse populations and relocate
them in the environment in order to temporarily relieve population pressure
on resources. Among tribal cultivators, warfare and the female infanticide
it engendered served as the primary mechanism to limit population (Harris,
1974; Kottak, 1991; Robbins, 2006).
As we have illustrated in this discussion of birth control in cross-cultural
context, sexual practices as well as fertility control are intricately tied to the
broader cultural system and articulate clearly with a number of cultural vari-
ables as well as ecological ones relating to demography, types of subsistence,
and adaptations. This chapter has covered much territory related to birth con-
trol and contraception. Contemporary birth control methods in industrialized
nations and nonindustrialized nations were discussed as well as methods used
throughout the ethnographic spectrum, illustrating the importance of a cul-
turally relativistic stance in understanding sex and reproduction.
Summary
1 Definitions for concepts related to birth control were offered including
contraception, population control, fertility, mortality, theoretical effec-
tiveness, and actual/use effectiveness rate and woman years.
2 Differences in population trends among industrialized and non-
industrialized nations were discussed.
3 Currently available methods of birth control in the United States were
presented.
4 Comparison of the prevalence, availability, and policy implications for
contraceptives in industrialized and nonindustrialized/industrializing na-
tions were provided.
5 The abortion controversy was discussed in the United States, other indus-
trialized nations, and nonindustrialized/industrializing nations.
6 Birth control was placed in cultural context: selected examples of indige-
nous contraceptive and birth control practices were provided.
7 Preindustrial examples of birth control including coitus interruptus, lac-
tation, abortion, and female infanticide were discussed, with an emphasis
on the Ju/wasi, Yapese, and Yanomamo.
1 Why is the birth control method of extended breastfeeding/lactational
amenorrhea not a reliable method for US women? Can you explain this?
2 What are your perspectives on the issue of abortion? Where did your
views on this issue come from? Is there any way that the Pro-Choice and
Anti-Choice perspectives can be reconciled?
Suggested Resources
Books
Carpenter, Laura M. 2005. Virginity Lost: An Intimate Portrait of First Sexual Experi-
ences. New York: New York University Press.
Boyer, Jesseca. 2018. “New Name, Same Harm: Rebranding of Federal Abstinence-Only
Programs.” Guttmacher Institute, Volume 21. https://www.guttmacher.org/
gpr/2018/02/new-name-same-harm-rebranding-federal-abstinence-only-programs.
Last accessed 9/4/19.
Riddle, John M. 1997. Eve’s Herbs: A History of Contraception and Abortion in the West.
Russell, Andrew, Elisa J. Sobo, and Mary S. Thompson, eds. 2000. Contraception across
Cultures: Technologies, Choices. Constraints. New York: Berg Press.
Sobo, Elisa Janine and Sandra Bell. 2001. Celibacy, Culture and Society: The Anthropol-
ogy of Sexual Abstinence. Madison: University of Wisconsin Press.
Scherper-Hughs, N. 1992. Death Without Weeping: The Violence of Everyday Life in
Brazil. Berkeley: University of California Press. 1992.
World Family Planning 2017 Highlights.” United Nations Department of Economic and
Social Affairs. https://www.un.org/en/development/desa/population/publications/
pdf/family/WFP2017_Highlights.pdf. Last accessed 12/30/20.
World Family Planning 2020 Highlights.” United Nations Department of Economic
and Social Affairs. https://www.un.org/development/desa/pd/sites/www.un.org.devel-
opment.desa.pd/files/files/documents/2020/Sep/unpd_2020_worldfamilyplanning_
highlights.pdf. Last accessed 1/2/21.
Websites
“Abstinence-Only-Until-Marriage Programs are Ineffective and Harmful to Young Peo-
ple, Expert Review Confirms.” Guttmacher Institute, 2017. https://www.guttmacher.
org/news-release/2017/abstinence-only-until-marriage-programs-are-ineffective-and-
harmful-young-people.
“New Name, Same Harm: Rebranding of Federal Abstinence-Only Programs,” Gut-
tmacher Institute, 2018. https://www.guttmacher.org/gpr/2018/02/new-name-same-
harm-rebranding-federal-abstinence-only-programs.
Ott, Mary A. and John S. Santelli. 2007. “Abstinence and Abstinence-Only Educa-
tion.” Current Opinion in Obstetrics and Gynecology, 19(5): 446–452. https://www.
ncbi.nlm.nih.gov/pmc/articles/PMC5913747/.
Planned Parenthood of America. http://www.plannedparenthood.org/. Last accessed
12/18/06.
9 Pregnancy and Childbirth
Chapter Overview
1 Examines pregnancy and childbirth as biological, psychological, and cul-
tural phenomena.
2 Views pregnancy and childbirth as a physiologically normal, healthy pro-
cess in which complications may occur.
3 Examines childbirth as the means to culturally create and extend kinship.
4 Examines male participation in the female experience of pregnancy and
childbirth.
5 Examines cultural responses to pregnancy, childbirth, and the postpar-
tum period.
6 Explains the stages of labor.
7 Explains the non-interventionist/interventionist birth continuum and
places US cultural birth practices along the continuum.
8 Discusses postpartum depression biologically, psychologically, and
culturally.
This chapter examines pregnancy and childbirth as biological, psychologi-

cal, and cultural phenomena, comprised of an integration of physical, socio-
cultural, and psycho-emotional variables. While focusing on physiologically
normal pregnancy and birth as a part of the hominid life cycle, the chapter
emphasizes how reproduction is culturally managed. It focuses on pregnancy,
birth, lactation (breastfeeding), and the postpartum period as essentially
physiologically normal processes. The chapter discusses pregnancy relative to
fetal development, and the impact that health and lifestyle have on the overall
experience.
Pregnancy and birth are key life cycle status changes. With the birth of a
child, a kin group is not only begun (the family of orientation) but is extended
(the family of procreation). The birth of a child forms a union between ex-
tended kin groups that can include blood (consanguineal) and marital (af-
final) ties. See Chapter 10 for a further discussion of kinship. It frequently
transforms the social status of both the biological parents (the genetic con-
tributors) and the social parents, those people involved in raising the child.
Raphael refers to this social transformation as matrescence and patrescence
Pregnancy and Childbirth 189
(Mead and Newton, 1967; Newton, 1981; Raphael, 1988). The individuals in-
volved such as the mother, the child, possibly the father, and the group are
affected by the pregnancy and birth process. The cultural management of
pregnancy and childbirth is discussed from industrialized and nonindustrial-
ized societal perspectives.
The anatomical and hormonal changes in a woman’s body are matched by
cultural concern over her pregnancy and the birth process. Many societies
recognize pregnancy as a unique state, placing the woman, and by extension,
the fetus, under special rules of behavior extending to diet, exercise, normal
routine, social and sexual interaction, and cultural/institutional participation.
The Fetus
The humanness of the fetus is culturally defined. Currently, industrialized
countries’ interpretations of when the fetus becomes human are controversial,
and are the topics of intense debate relative to abortion and certain forms of
birth control. For example, since the 1980s, conservative religious groups in
the United States believe that human life begins at conception and take strong
Figure 9.1 Embryo seven weeks after conception.

positions about assisted reproductive technology (ART), stem-cell research,
and EC (emergency contraception). In colonial days, a fetus was not defined
as alive until the onset of quickening, or fetal movement, usually detected in
the fourth month during the second trimester of pregnancy (Bullough, 1976).
Late twentieth-century biomedical explanations trace fetal development
by trimesters. Much of the organ and system development occurs during the
first trimester (see Figure 9.1). In these first three months when neural, brain,
muscular, and organ development is forming and sexual differentiation begins,
the fetus is seen as extremely vulnerable to external factors such as drugs,
pollutants, toxins, or X-rays. For this reason, early confirmation of pregnancy
and modification of diet, drug use, sleep, and exercise are seen by healthcare
providers in industrialized societies as very important to healthy fetal devel-
opment. The second trimester, months 4–6, involves elaboration of skeletal,
muscular, and system development. It frequently is an end to the nausea expe-
rienced by some women in industrialized societies and to the breast tenderness
caused by high levels of progesterone secreted by the mother. The third tri-
mester, months 7–9, is generally a period of major weight gain in the fetus and
ongoing maturation of systems in preparation for postnatal life. The testicles
descend into the scrotal sac during the third trimester. Hearing, however, is
the only system totally mature at birth.
The Pregnant Female

Women’s bodies during these three trimesters undergo radical changes. There
are surges and elevated levels of estrogen and progesterone in her body that
may initially contribute to morning sickness or nausea. Morning sickness is
not a universal phenomenon. It is not reported as often in nonindustrialized
societies as it is in the United States. This may be due to the higher com-
plex carbohydrate diet in nonindustrialized societies than in the industrial-
ized countries. Some recommendations to the pregnant woman experiencing
morning sickness are to eat whatever she can swallow and keep in her stom-
ach, regardless of its nutritional component. Some food ingested is better than
none or food that is rejected (Erick, 1994).
The woman’s breasts increase in size by several pounds as the milk ducts,
stimulated by pituitary hormones such as LTH, prepare for lactation. Her uterus
increases in size to accommodate the fetus, amnion, or bag of water, placenta,
and umbilical cord. Weight gain, slight separation of the pubis, slight lowering
of the red blood cell count, and slightly elevated blood pressure are all normal
physiological developments in pregnancy.
Labor and Birth

The birth process itself is a normal physiological event in which problems may
develop for the fetus, mother, or both. It is estimated that in otherwise healthy
pregnant women, about 92–95 percent of births are normal (Arms, 1975;
Boston Women’s Health Collective, 1976, 1984, 1992, 2005; Davis-Floyd, 2001;
Reibel, 2004). This approach is a radical departure from the accepted view in
the United States. Currently, we in the United States, structure pregnancy
and childbirth as a physiologically dangerous, pathological state that is med-
ically “managed” (Davis-Floyd, 1989/1990, 1992, 2001; Johanson, Newburn,
and MacFarlane, 2002; Mitford, 1992; Reibel, 2004; Williams, 1989; Williams
et al., 1985).
Although the exact causes for the onset of labor are unknown, it is probably
a function of the interaction of fetal maturity and oxytocin, a labor-stimulating
pituitary hormone. Labor is generally depicted as a three- or four-stage process
depending on the medical text used. Prior to or early in the first stage of labor,
“show” (i.e., the mucous plug) is usually expelled. Show is a bloody mucoid
substance that covers the os (cervix) during fetal development.
The first stage of labor is characterized by several events. The os fully dilates
or opens during this stage and generally takes several hours. A fully dilated
os is ten centimeters or five fingers in breadth. In the United States, digital
or finger vaginal exams are regularly performed during this period to assess
the state of dilation. The cervix effaces during the first stage of labor as well.
Effacement, measured from 0 percent to 100 percent, is the gradual softening
of the cervix. A “softer” cervix allows for greater ease in the passage of the
fetus through the os. The bag of water or amniotic sac may break during this
or subsequent stages of labor or the baby may be born with the amnion intact,
called the caul. If the water does not break for a woman in labor in the United
States, the amnion is usually ruptured by a medical attendant.
Transition, the second stage of labor, occurs when the cervix is fully dilated.
Transition is the passage of the baby’s head through the dilated os and may
take several minutes to several hours. The third stage of labor is the actual
birth of the baby through the introitus (see Figure 9.2). The perineum stretches
to accommodate the baby.
Stretching the perineum is culturally managed and an example of the bio-
cultural nature of sex and reproduction. In most societies outside the United States,
the perineum is stretched through massage, application of warm compresses, or
an upright birth position that allows the baby to pass through the introitus at an
angle which fits the mother’s body (Fisher, Bowman, and Thomas, 2003; Janssen
et al., 2002; Jordan, 1983, 1993; Michaelson, 1988b; “Midwives and Moderniza-
tion,” 1981). In the United States for the past several generations, in anywhere
from one-third to three-fourths of the births, the perineum is stretched surgi-
cally with an episiotomy, an incision in the perineum. This procedure is con-
troversial. Proponents in favor of episiotomies say they reduce perineal tearing.
Opponents to episiotomies state that tearing rarely occurs if upright birthing
positions and massage are used (Arms, 1975; Boston Women’s Health Collec-
tive, 1984, 1992; Davis-Floyd, 2001; Jordan, 1983, 1993; Michaelson, 1988b).
In an article in the Journal of the American Medical Association, researchers
recommended against routine episiotomies, stating that they offered no ben-
efit, increasing both pain and the chances of tearing (Hartmann et al., 2005).
Figure 9.2 Stages of childbirth.

Figure 9.3 Thirty-minute-old infant.
In response to opposition to overly medicalized birth, innovations such as wa-

ter births, more flexibility in birthing positions, and birthing chairs (originally
developed for birthing women in Europe in the 1500s) have been introduced
into maternity suites in some “progressive” US hospitals as the newest, most
female-centered aspect of high-tech childbirth.
The fourth stage of labor consists of the expulsion of the placenta. During
this period, the umbilical cord is cut. In most societies the baby is cleaned to
remove blood and the vernix, the waxy, protective coating that covers the baby
in utero. In most societies, the baby and the mother have some contact at this
time. This is the first stage of infant-mother bonding. Again, this is a controver-
sial belief in the United States, where babies and mothers in hospitals frequently
are separated shortly after birth for up to several hours, ostensibly to give the
mother rest (Boston Women’s Health Collective, 1992, 2005; Mitford, 1992).
After the expulsion of the placenta, the uterus starts a six-week process of
involution, or return, to its non-pregnant size and shape. Involution is also
culturally managed by massage in some nonindustrialized societies (Fuller and
Jordan, 1981; Jordan, 1983, 1993), and through the use of drugs in the United
States (Davis-Floyd, 2001; Jordan, 1983, 1993; Michaelson, 1988b). In many
societies, women are encouraged to nurse immediately after birth in order to
stimulate milk production and to help the uterus to involute. In general, the
United States still sees pregnancy as a biomedical condition that needs to be
medically controlled. Other societies see it as a normal state in which problems
may or may not occur (Davis-Floyd, 2001; Jordan, 1983, 1993; Michaelson,
1988b; “Midwives and Modernization,” 1981; Williams et al., 1985).
Cultures treat the placenta differently. We dispose of it. In other cul-

tures, it is buried in a tree or underground, the umbilical cord may be
worn around the neck as an amulet until it dries and falls off, or the
placenta may be eaten.
Although recognizing and attending to the physiological aspects of labor and

birth, many nonindustrialized societies see birth as a significant social event.
Birth unites women and reinforces their bio-social sameness (Frayser, 1985;
“Midwives and Modernization,” 1981). Birth attendants often are known and
respected women in the cultures in which they practice. They assist, sup-
port, and are with the parturient woman before, during, and after childbirth
(Boston’s Women’s Health Collective, 1992, 2005; “Midwives and Moderniza-
tion,” 1981; Mitford, 1992). Birth also creates the family of procreation for the
parents and family of orientation for the child.
Birthing Models
There are two general models developed as the cultural response to preg-
nancy: the interventionist and non-interventionist. These models exist on
a continuum, since all cultures intervene in the pregnancies and births of
their members. Those societies toward the non-interventionist end tend to
view pregnancy and birth as a natural phenomenon and emphasize the socio-
psychological dimensions over the physiological. In these societies, the well-
being of the mother and fetus is a primary concern with the expectation that
the woman needs support. The physical birth process, while long and “labori-
ous,” is generally believed to occur on its own timetable. This model is char-
acteristic of many societies outside the United States and the United States
prior to the late nineteenth century (Davis-Floyd, 2001; Fisher, Bowman, and
Thomas, 2003; “Midwives and Modernization,” 1981).
The interventionist model is characteristic of current US society, even
with the range of birthing alternatives available such as birthing centers,
family-centered childbirth, water births, and the increased use of midwives and
doulas. Adopted from the Greeks, doulas are women who provide support for
pregnant women throughout the pregnancy and early postpartum period. In
2017, over 98 percent of the births in the United States occurred in hospitals
(MacDorman and Declercq, 2019). Birth is primarily viewed as a biomedical
phenomenon with a best-case and worst-case scenario (Davis-Floyd, 1988, 2001;
Janssen et al., 2002; Reibel, 2004). The interventionist view perceives childbirth
as inherently dangerous and prepares for the crisis situation as a general rule.
Thus, there is much medical and technological intervention in normal as well
as complicated births (Davis-Floyd, 1992, 2001; Reibel, 2004). This includes
routine use of internal and external fetal monitors to chart the fetal heartbeat,
episiotomies, and the use of IVs and drugs in the vast majority of births (Davis-
Floyd 2001; Jordan, 1983, 1993; Michaelson, 1988b; Reibel, 2004; Sargent and
Stark, 1989; Williams, 1989). It also reflects a rising caesarean rate of 31.9 per-
cent of the hospital births in this country in 2018 (Martin et al., 2019).
Cultures address pregnancy through the postpartum (post-birth) period in
a variety of ways. These include the role of the couvade, birth attendants,
birth practices, and breastfeeding customs. The couvade is a culturally created
bio-behavioral phenomenon in which the father can simulate the pregnancy
and birth of the woman who is bearing his child. Fathers may participate in
the rituals and ceremonies accompanying the birth. Birth attendants are
those people who take care of the woman during her labor, the birth of the
baby, and immediately after. Who these people are varies widely. Outside the
United States, they usually are female; they usually are known to the preg-
nant woman; and they may be midwives, women who are trained in pre- and
post-natal care and indigenous birthing practices. These women attend to the
socio-psychological and physical needs of the woman and her baby before,
during, and after birth (Faust, 1988; “Midwives and Modernization,” 1981;
“Quality of Midwifery Care Given Throughout the World,” 2000; Raphael,
1988; Semenic, Callister, and Feldman, 2004).
The following passage is a description of a birth in a Mayan community in
Latin America. It provides an interesting contrast to our biomedical approach.
Notes from a Field Log: Doña Bernarda at Work
Michele Godziehen-Shedlin, an anthropologist who works in Central

America, wrote up her observations of a birth to a sixteen-year-old girl.
Her rich description focuses on the support and presence of female atten-
dants and the girl’s husband during the labor and birth process. The mid-
wife, Doña Bernarda, incorporates indigenous and biomedical methods in
assisting the girl and also works with a medical doctor. The emphasis on
birth as a normative part of a woman’s life experience is paramount in this
description. The ritual aspects of this transition for the mother and baby
are an integral part of the birth.
Doña Bernarda examined her, massaged her; she was lying down. First,
four of the five women helped her—two aunts held her, with Doña Bernarda
at her feet and me holding her hand. She was made to squat, first supported
by an aunt, later by an older man, and finally by her husband. She (Doña
Bernarda) never stopped, her hand under the black Indian skirt (chinquete),
her words and sounds constantly reassuring the tired, frightened girl.
(Godziehen-Shedlin, 1981: 13–15)
Cecilia Van Hollen, an anthropologist, studies maternal and child health

care in Tamil India. In her book, she discusses how working and lower
class women engage the services of both midwives and biomedical practi-
tioners during their pregnancies and births (2003).
Since the mid-nineteenth century in the United States, the entire birth pro-
cess has been increasingly medicalized, removed from the home and familiar
settings, and has become a mostly male-physician specialty.1 Hospitalization for
childbirth usually means the woman is in an unfamiliar, socially sterile, medical
environment, attended by a series of strangers. Although women may have a
number of friends or family with them during labor and birth in the United
States currently, the physiological aspects of pregnancy are emphasized over the
socio-psychological. Women are delivered in the United States; they do not give
birth. In nonindustrialized societies, the locus of control rests with the pregnant
woman; in the United States, control rests with her medical birth attendants
(Davis-Floyd, 1992, 2001; Martin, 1987). In many nonindustrialized societies,
birth attendants are integrated into the fabric of the woman’s life; in the United
States, they are distinct, discrete entities who act on her.
Examples of birth attendant-parturient woman relationships from Greece,
Latin America, and Egypt illustrate the importance of this role. The following
examples illustrate the shared characteristics of the birth attendants. These
older, experienced females may be involved in non-obstetric health care as
well. The birth attendants are known to the pregnant woman and are part of
her social support system. They provide her with care, advice, and guidance
from pregnancy through the postpartum period.
In Greece, this woman is called the doula. She is particularly helpful in
establishing a breastfeeding pattern and assisting the postpartum woman. She
gives advice, helps with the daily routine, and provides socio-emotional sup-
port in teaching the new mother how to breastfeed. She temporarily becomes
part of the new extended kin household (Raphael, 1988).
In Latin America, midwives are often called doña, a title of respect (Faust,
1988; Godziehen-Shedlin, 1981; Sukkary, 1981). These women take seriously
the overall health of their patients or clients, and frequently care for both
their gynecologic and obstetric needs. These midwives monitor diet, social
activity, and if government-trained, may record maternal blood pressure, fetal
heart rate, and other physical signs during pregnancy (Faust, 1988). In much
of Indian Latin America, pre- and postpartum massage and binding, in which
the woman’s abdomen is tightly wrapped, are part of prenatal and perinatal
care. This necessitates the midwife’s presence and her support of the pregnant
woman (Fuller and Jordan, 1981).
Egyptian midwives or dayas, also provide known, continuous pre- and post-
natal care. They stay with the new mother for seven days after birth, taking
care of both her and the baby. As with the doula, dayas become part of the
extended kin household, more like a family member than an outsider (Suk-
kary, 1981).
Fathers have various degrees of involvement in the pregnancy. In some soci-
eties, the sociological role of the prebirth father is highly ritualized through the
couvade. He may “experience” morning sickness and labor, and undergo compa-
rable forms of food, activity, sexual taboos, and modifications of his daily routine
that the mother of his child incurs. The father may take to his hammock and ex-
perience simulated labor contractions during his partner’s birthing process. The
couvade is a cultural means of acknowledging and enjoining men to participate
actively in the pregnancy and birth phenomenon (Kottak, 1991; Raphael, 1988).
For most of the twentieth century in the United States, fathers were not al-
lowed to participate actively in pregnancy and birth. They were forbidden to be
with women during labor and birth. They were seen as economic contributors,
but not as interested, involved participants during the pregnancy. Since the mid-
to-late 1960s, childbirth advocates have actively encouraged greater participation
by fathers, extended kin, and friends. This has resulted in the involvement of a
greater number of fathers and others in women’s pregnancy, birth, and postpar-
tum care (Leavitt, 2003; Raphael, 1988). The father-involved childbirth move-
ment in the United States may serve some of the same functions as the couvade.
In the United States, some heterosexual couples talk about “our preg-
nancy,” and men wear a strap-on “pregnant-stomach” to simulate later
stages of pregnancy.
Confinement refers to the period spanning the pre- through postpartum

(birth) phase. Most societies, including the United States, modify pregnant,
birthing, and postpartum women’s behavior in various ways. Dietary and sex-
ual habits are often changed. Pregnant women experience restrictions of their
daily routine relative to work, sleep, and social activities here and in other
societies (Daniels, 1997; Frayser, 1985). For example, we caution women to
limit their intake of all forms of drugs during pregnancy, especially caffeine,
nicotine, alcohol, and recreational drugs. We encourage a “balanced diet” rich
in grains, calcium, fruit, and vegetables. Among the Maya in the Yucatan,
women are encouraged to eat chicken and soups (Jordan, 1983, 1993). Our
postpartum sex taboos usually end within six weeks; among the Ju/wasi of the
Kalahari Desert in South Africa, they last several years (Frayser, 1985).
The actual birth of a child in the United States falls to the interventionist
end of the continuum. Most women want and receive drugs for pain, have an
episiotomy, and undergo a “prep,” a surgical preparation procedure that may
involve shaving the pubic hair and receiving an enema, in order to “clean out”
the intestines. Most women are hooked up to IVs and fetal monitors, either
external or internal (Davis-Floyd, 1992, 2001; Janssen et al., 2002; Johanson,
Newburn, and MacFarlane, 2002). Rarely does a woman wear her own clothes;
jewelry may be removed and she wears a hospital gown (Michaelson, 1988b).
Ironically, the medical interventions in pregnancy and childbirth in the
United States do not make them safer. We have the highest rate of infant and
maternal mortality rates in the industrialized world (CDC, 2017; Chaya and
Dusenberry, 2004). There are a number of explanations for this:
1 We have more girls under fifteen years of age giving birth than in other
industrialized societies. Younger adolescents have immature reproductive
tracts, tend to smoke more, and have poorer nutrition than older adoles-
cents and adults. These behaviors can result in more complicated preg-
nancies and births.
2 We have differential access to health care in this country; poorer people
get less health care and it is of poorer quality than found among mid-
dle-class, insured people.
3 Reproductive technology allows women to become pregnant who would
not otherwise, and older women (those in their forties getting pregnant
for the first time) who are pregnant have more complications.
4 Our interventionist approach to almost all births, not just those with
complications, results in more procedures such as C-sections that increase
the risk of complications.
Outside the United States, pain may be relieved with herbal remedies or talked
through. Childbirth pain is seen as normal and tolerable, part of a process to get
the baby born (Godziehen-Shedlin, 1981; Jordan, 1983, 1993; Newton, 1981).
Traditionally, episiotomies were unknown. The perineum stretches through
the upright birthing position, spontaneous rupture of the bag of water, mas-
sage, and hot compresses (Jordan, 1983, 1993). “Preps” are unknown and the
woman’s own clothing is usually worn. Babies and mothers are kept together
after birth; babies usually are nursed immediately and whenever they cry. It is
interesting that the counterpart of high-technology childbirth in the United
States, “family-centered childbirth,” advocates procedures and behaviors that
are common and widespread practices in cultures outside the United States.
These include recent “advances” such as birthing rooms and birthing chairs,
having women move around during labor, or having a childbirth coach present
to help the woman.2 Most recently, they include shorter hospital stays. Post-
partum infant-mother contact, a given in societies outside the United States, is
beginning to be re-established here through the practice of “rooming in,” where
for most of a twenty-four-hour period, the newborn and mother share a room.
Postpartum
The postpartum period, a bio-social event, extends from the birth of the baby
until the woman resumes her full pre-pregnancy roles and new status in the
society as a mother and adult. This may take several weeks, as in the United
States, or longer in other societies such as the Ju/wasi where postpartum sexual
taboos last two to three years (Frayser, 1985; Murdock et al., 1965). Biologi-
cally, the woman’s body returns to a non-pregnant state: the uterus involutes,
and her menstrual cycle resumes, irregularly at first depending on whether she
nurses. Nursing is common outside the United States and engaged in sporad-
ically and for shorter periods of time in the United States. Nursing may in-
hibit ovulation when it lasts for greater than eighteen months, when it occurs
regularly and without interruption, and when it is correlated with relatively
low body fat in the lactating female (Ember and Ember, 1990; Frayser, 1985).
Breastfeeding then serves as a means of birth control under these conditions.
For most US women, nursing is not a reliable means of birth control for several
reasons. First, most US women do not breastfeed long enough for the hormonal
suppression of ovulation to occur on a regular basis. Second, most US women
do not nurse regularly enough and give “supplemental” feedings—bottles of
juice, formula, or solids—and thus interrupt the rhythm that is established by
frequent, regular nursing. Third, most US women’s body fat is too high to sup-
press the H-P-G axis regulation of ovulation. To reiterate, nursing as a means
of birth control is not recommended for most women in the United States.
Breastfeeding itself is nutritionally complete for younger infants, and helps
to protect them from disease by supplying them with their mother’s antibodies.
HIV-infected breast milk can be passed from the lactating woman to the nurs-
ing infant. There is international debate and controversy regarding whether
women with either unknown HIV status or who are HIV infected should
breastfeed (Altman, 1998) (see Chapter 16).
Postpartum depression, well documented in the United States, and less
so in other industrialized and traditional societies, is both physiological and
cultural. The elevated levels of estrogen and progesterone during pregnancy
drop dramatically after birth. In addition to this internal hormone withdrawal,
many women in the United States do not have extended kin and non-kin
social networks and models for child rearing and social support. They are ex-
pected to read about child rearing and turn to the experts, health care, and
social service people for help with parenting. Frequently, they do not know
what they are doing and are alone at home. They may be isolated from other
adults and have one or more infants, toddlers, and other young children to
care for. The response to this situation may be “postpartum depression” (Bos-
ton Women’s Health Collective, 1992, 2005; Fisher, Bowman, and Thomas,
2003; Semenic, Callister, and Feldman, 2004).
In nonindustrialized societies, an individual exists as part of the larger
social group, generally the extended family. A postpartum woman is part of
that group as a continuous aspect of her life. Her midwife, as discussed, may
also join this group briefly in the first few days or weeks after birth. Although
the confinement period may extend through part of this time, it also offers
benefits: rest from the daily routine, regular food, and relaxation from overall
social and familial obligations. At the same time, mother-infant bonding
occurs.
The relative separation of woman and baby from hour-to-hour social obliga-
tions may also provide some immunity from infection for the baby.
The pregnancy-through-postpartum continuum is an example of a physio-
logically widespread phenomenon that receives cultural attention wherever it
occurs. The variability and forms of interpretation are culture-specific. They
range from highly technological to highly psycho-sociological.
Summary
1 Pregnancy and childbirth are bio-cultural phenomena. Cultures intervene
in the management of pregnancy and birth in a variety of ways.
2 While this chapter treats pregnancy and birth as a physiologically normal
process, the dominant view in US culture for over 150 years has been
that they are dangerous processes requiring medical management and
intervention.
3 Birth creates and extends kin groups.
4 Pregnancy generally is discussed in terms of trimesters relative to fetal
development and changes in the woman’s body.
5 Cultures involve the father of the child in the woman’s pregnancy and
birth in a variety of ways.
6 Labor and birth are a four-stage process that is managed culturally with a
wide range of interventions.
7 The postpartum period is culturally defined and involves biological and
social dimensions.
1 What are some of the cultural values in the United States that support
the notion of pregnancy and childbirth as dangerous phenomena that
need to be medically controlled and managed?
2 What can we learn from cross-cultural childbirth practices and what can
industrialized societies contribute to childbirth practices cross-culturally?
Suggested Resources
Book
Jordan, Brigitte. 1992. Birth in Four Cultures: A Cross-Cultural Investigation of Childbirth
in Yucatan, Holland, Sweden and the United States. 4th ed. Long Grove, IL: Waveland
Press.
Websites
La Leche League USA. https://lllusa.org. Last accessed 11/04/19.
Cesarean Delivery Rates by State. https://www.cdc.gov/nchs/pressroom/sosmap/cesar-
ean_births/cesareans.htm.
10 Sexuality through the Life
Stages, Part I
Early Childhood Sexuality
Chapter Overview
1 Introduces definitions of childhood and parenting.
2 Outlines the various functions of the family.
3 Discusses kin groups and family forms including the nuclear and extended
family.
4 Presents the importance of marriage rules and patterns.
5 Provides an overview of kinship and its various forms and structure.
6 Reviews the major theories of the incest taboo, including issues of uni-
versality and the interrelationship of kinship structures with the incest
taboo.
7 Discusses incest in the United States.
8 Traces historically the changing perspectives of children’s sexuality in in-
dustrialized societies.
9 Introduces major theories of childhood sexuality including the psycho-
analytic views of Freud and Horney as well as those of pediatrician Dr.
Spock.
10 Presents evidence of the development of children’s early capacity for sex-
ual responses as well as masturbation and child-child sexual experimenta-
tion in the United States.
11 Presents an overview of nonindustrialized society’s childhood sexuality to
emphasize its diversity and the cultural shaping of children’s development.
Definitions
Early childhood sexuality is a highly charged issue, which is made more com-
plex by news stories of child molestation, incest, and the violation of a child’s
innocence. To comprehend fully the issue of childhood sexuality, researchers
focus on the way culture interprets childhood as a specific time with a begin-
ning and end with its own social and physiological changes. This necessitates
that one must first understand the bio-cultural aspects of childhood from a
physiological view, as well as the role that one’s culture assigns to the phys-
ical body, in particular the genitals. An understanding of childhood relates
202 Early Childhood Sexuality
to cultural conceptions of parenting, cultural notions of the family as well as
kinship and descent.
It is important to remember that one of the unique aspects of human evo-
lution is cooperation. Individuals who are not necessarily biologically related
have, in our evolutionary past and under various cultural conditions, made a
valuable contribution to survival of the group through parenting and nurtur-
ing the young. It is part of our deep human capacity to bond. Many children
today have godparents who act in the place of the family in medical emergen-
cies, death, or other situations necessitating help. In the South, the “courtesy
aunt/uncle” is a family friend who acts as the parents if the necessity arises.
This may include nothing more than picking up a child from playschool, but
it is a bond that is forged through time and respect (“Fictive Kin,” 2006; Kot-
tak, 2004). Godparenting is also referred to as compadrazgo in Latin American
cultures. The godparents may agree to raise the child Catholic if the parents
are unable to, or if they die.
It has been posited by physical anthropologists that one of several factors
accounting for female hominids’ long postmenopausal lifespan is their contri-
bution to survival of infants and children through caregiving. Human females
are unique in their long post-reproductive lives. What information is available
from our closest relatives confirms that reproduction and the lifespan converge
in non-human primates. It is only in human females that longevity far exceeds
the period of reproductive fertility. As grandmothers and socio-partners, we
can imagine the enormous contribution of human females to the survival of
the group in evolutionary terms. Hominid females, in the past and today, act
as role models, caregivers of the young, parent substitutes, providers of the vast
reservoir of knowledge in regard to the socialization of the young, and as edu-
cators of new parents. Like most human behavior, human parenting is a biolog-
ically adaptive behavior that interacts with the socio-cultural dimension. This
is also true of kin groups in which biological relations are culturally shaped.
It is easy to forget, given the truncated nuclear families found in industrial-
ized societies, that kin and family are the core units of culture. Children are
born into a kin group in which descent is reckoned. For the majority of the
world’s cultures, descent is unilineal (Holmes and Schneider, 1987: 387). This
refers to tracing descent through only one side of the family, either the mother
or the father; unlike Euro-Americans who reckon descent through both the
mother and father (note indigenous groups in North and South America were
largely unilineal in descent). Kin groups and descent are important for our
discussion because they relate to the social positioning and cultural meaning
of children in a society; to issues of parenting and parenting roles; to rules of
incest, marriage; and reproduction boundaries; and why paternity certainty is
important under some conditions and not others.
The industrialized worldview of parenting often emphasizes its connection
to biological paternity or “paternity certainty.” This is in reference to the bio-
logical principle that an individual is usually aware of whom his/her mother is,
but without the use of technology to determine genetic heritage, the biological
Early Childhood Sexuality 203
father is not readily apparent. Even in a minority of cases such as adoption,
this quest is documented by people’s desire to find their “biological parents,”
often at great cost and expense. We suggest, however, that family is socially
constructed through the meaning we give to biology.
In understanding how family is a bio-cultural phenomenon, let us explore
briefly the cultural emphasis on the importance of paternity certainty and the
conditions that are correlated with its emphasis (see Chapter 3). These vari-
ables include male-centered descent rules (tracing descent through the father’s
side of the family) and/or residence patterns. Concern with paternity certainty
is also associated with certain kinds of subsistence strategies, specifically those
found in horticultural societies that are under resource pressure and in agricul-
tural societies. These kinds of societies are also associated with male-centered
descent systems (patrilineal systems are discussed in a later section). Thus, cer-
tain kinds of horticulture (farming characterized by slash-and-burn techniques
and fallow periods between plantings) are associated with male-oriented de-
scent patterns. And agricultural societies (using irrigation, ploughing, draft
animals, and fertilizer) generally are associated with this pattern. Finally,
concern with paternity certainty is found in societies in which males hold
privileged positions, such as the majority of agricultural societies, some hor-
ticultural societies, and industrialized nations generally. It is hypothesized
and supported by a good deal of evidence that these conditions are correlated
and historically related to one another (Brettell and Sargent, 2005b: 135–141
among numerous others; Martin and Voorhies, 1975).
For example, male-centered descent systems wherein individuals trace their
ancestry through the father’s kin play a role in the sex and gender system of a
society. In some types of horticultural and generally in agricultural societies,
the male line of descent establishes the continuation of the family property
and business. Thus, in the Sudan, according to the legal system dominated by
Islamic law, women cannot inherit property. Nor are they positioned to sup-
port themselves due to lack of educational and employment opportunities as
well as cultural customs related to the separation of the genders and ideologies
of gender and work. This places them in a position where they must marry, or
risk becoming a social and economic liability to their families (Gruenbaum,
2005: 481–494). Women must be virgins or they bring shame on their family.
Virginity is therefore a mechanism that functions to support the certainty
of paternity and is linked to ideas of kinship and the family (Gruenbaum,
2005). Descent and kinship rules around inheritance can have profound con-
sequences on the lives of people, especially with regard to women and their
status. Concern over biological paternity is clearly not a random cultural con-
cern but must be understood in relationship to the broader cultural context,
especially kinship rules.
Kinship is important for ordering human social relations and creating
groups and boundaries. Throughout the course of evolution and in most non-
technologically complex societies, the family is the primary unit for production
and consumption. Kin groups are formed through marriages and reproduction.
Marriages should not be confused with mating, which is defined in terms of
premarital and extramarital sex. A definition of heterosexual marriage then
can be stated as follows: Marriage is the “socially approved relationship be-
tween a socially recognized male (the husband) and a socially recognized fe-
male (the wife) such that the children born to the wife are accepted as the
offspring of both husband and wife” (Kottak, 2004: 8). Note that these spouses
need not always belong to the other sex nor are they necessarily limited to a
single spouse at a time (Blackwood, 2005a; Bolin, 1996b; Kottak, 2004: 281).
Marriage partners will share economic, reproductive, and sexual obligations.
The functions of marriage are numerous and relate to these obligations. Mar-
riage provides a setting that facilitates infant survival as well as a stable setting
for children’s socialization. Group survival is enhanced by extending social
relations and providing sexual outlets and economic advantages to the par-
ticipants (Ferraro, 2004: 195; Holmes and Schneider, 1987: 388). As will be
discussed, all groups have incest taboos, which prohibit sex and marriage with
various kin and hence structure kin groups.
Just as there are socio-cultural rules regarding whom one may have sex with
in the family (incest rules), there are also marriage rules. There are two forms
of marriage rules: exogamy and endogamy. Exogamy prohibits marriage within
one’s own group. The definition of group will vary from that of a particular
group of kin, to village, or groups of villages (Ember, Ember, and Peregrine,
2005: 360). According to alliance theory, exogamy creates economic and
political relationships between groups, some of which might otherwise be in
conflict, and/or forges broader social networks and economic ties providing
greater integration. For example, the Indian village of Rani Kera with 150
households was linked to 400 other nearby villages through the practice of vil-
lage exogamy (Ember, Ember, and Peregrine, 2005: 361). Endogamy is marriage
that must take place within the group. This may include groups of relatives,
the tribe, or even a caste or class. Hindu castes, although illegal but still prac-
ticed, endorse caste endogamy, marrying within the same caste, but not below
in order to avoid the risk of ritual pollution (Ferraro, 2004: 201). Endogamy
does not refer to marriage within nuclear families, but may include marriages
between cousins or other related individuals. Descent theory regards endog-
amy as a vehicle for families to contribute to cohesion and solidarity by keep-
ing wealth, power, and prestige within the group (Cohen and Eames, 1982:
121–122; Kottak, 2002: 406–407).
There are primarily two types of families: the nuclear family and the ex-
tended family. Nuclear families consist of the parents and their progeny. While
blended families, single-parent-headed households, and extended families exist
in the United States, the nuclear family is regarded as the cultural ideal rep-
resented in a variety of discourses including the media and political rhetoric.
Other forms of marriage are also prevalent such as the blended family, which
represents children from previous marriages, single female- or male-headed
households, extended families, and childless couples. Extended families in-
clude consanguineal (blood) and affinal (marriage) relatives in addition to the
nuclear ones. In nonindustrialized societies, the extended family usually in-
cludes relatives from either the male or female lineage and is the most common
family form (Ember, Ember, and Peregrine, 2005: 366–368).
There are several types of marriage represented in the cross-cultural spec-
trum. These include single mateships, which are composed of two spouses.
According to Ford and Beach’s (1951) classic study using ethnographic sam-
ples, 16 percent of the world’s societies required this form, while in 84 percent
of them, men could practice polygyny if they could arrange it. Polygamy is
legally practiced or societally accepted in 33 countries and accepted by part of
the population in 41 countries (United Nations, 2011: 4). The Demographic
and Health Survey (DHS) carried out from 2000 to 2010 indicates that 10–53
percent of women aged 14 to 49 had co-wives.
It has previously been suggested that only a few of the men in societies that
prefer polygyny are actually able to practice this highly priced endeavor—it
takes a multitude of wealth to sustain multiple wives (Broude, 1994; Ponzetti,
2003; Saxton, 1993). A recent model suggests that the practice of polygyny
is limited by two factors: wealth inequality that decreases the availability of
wealth for men to pursue polygyny and low fitness returns for wives (Ross et al.,
2018: 1).
The generic term for multiple spouses is polygamy, while polygyny refers
to multiple wives. However, in 49 percent of the polygynous societies single
mateships are actually the rule, since a man must have a certain amount of
economic wherewithal to acquire additional wives. As is illustrated by the
Tiwi of Australia, once a man has demonstrated that he is a good prospective
husband in terms of his status and economic condition, having several wives
enhances his economic standing considerably (Hart and Pilling, 1960). In 14
percent of the polygynous societies, the only acceptable additional wife is her
sister. This is known as sororal polygyny.
Another form of marriage is polyandry in which a woman may have more
than one husband. Although the percentage is small, less than 1 percent, this
pattern has been common in Tibet, India, and Sri Lanka and has also been re-
ported historically among the Marquesans of the Pacific (Levine, 1988; Suggs,
1966). However, polyandry is currently no longer practiced in some areas and is
under pressure to change in others (Cohen and Eames, 1982: 126–127; Ember,
Ember, and Peregrine, 2005: 365). It is believed that less than a dozen such
cultures are currently in existence, and the cause for this marriage pattern
is unknown. The most common polyandry is known as fraternal polyandry,
which occurs when the multiple husbands of one woman are brothers. Possible
advantages stemming from polyandry include keeping scarce resources, such as
land, within the patrilocal family (Ponzetti, 2003: 1096). Fraternal polyandry
occurs in Nepal and India where brothers may marry one woman and live
patrilocally. All the brothers are recognized as the wife’s husbands, and all
take on the parenting role of father to her children. The wife has equal sexual
access to all the brothers. In fraternal polyandrous societies, sororal polygyny
may also be practiced (Schultz and Lavenda, 2001: 476–477).
Associated polyandry occurs among the Sinhalese of Sri Lanka (Levine and
Sangree, 1980), and is reported in the Pacific and among indigenous peoples of
North and South America (Schultz and Lavenda, 2001: 407–408). Associated
polyandry refers to a marriage in which a woman may have multiple husbands,
but these husbands are unrelated. The Nayar represent one of the most famous
anthropological reports of this kind of polyandry. The Nayar woman engages
in a ritual marriage to a man from a linked lineage. After three days of seclu-
sion where sex might occur if the wife is old enough, the couple parts and they
go their separate ways with no further obligations or relations. The woman is
then free to marry and have sexual relations with men of her own choosing as
long as they are of the same caste or higher (endogamy). The only restriction
is that these husbands cannot be brothers. This system is referred to as one
of visiting husbands. The men and women in these relationships have more
than one spouse. The households are consanguineal ones in that a woman
lives with her children, her sisters, and her sisters’ children. The marriages
are valuable for their alliance functions, not economic ones. Men take on fi-
nancial responsibility for their sisters and sisters’ children (Kottak, 2004: 257;
Schultz and Lavenda, 1990: 301–302).
Like polygynous marriages, polyandrous ones reflect adaptations to subsis-
tence conditions. In Tibetan fraternal polyandry, polyandrous marriages help
maintain family landholding units against possible subdivision through indi-
vidual inheritance and partition of lands. The ecological conditions are such
that households must pursue both agriculture as well as animal husbandry in
order to survive. In such a situation, a division of labor among cohusbands is
advantageous (Goldstein, 1987: 39–48; Ponzetti, 2003: 1096).
Other forms of marriage exist but are not widespread. These include a form
of group marriage practiced by the Oneida utopian Christian community in
New York. All members regarded one another as spouses. As a result of local
hostility, this system was discontinued in 1879 (Gregersen, 1994: 310). Out of a
study of over one hundred of these “multilateral marriages,” only 7 percent ex-
ceeded five years (Constantine and Constantine, 1973; Ponzetti, 2003: 1096).
Other forms include woman marriage, as among the Nuer, in which two women
are married. One woman takes on the role of a social male and arranges for
“her” wife to become pregnant by “another” man. The woman-husband then
becomes the social father of the child (Blackwood, 1984a: 56–63; Brockman,
2004: 688; Cohen and Eames, 1982: 128–129). The levirate and sororate rep-
resent marriage systems related to the death of spouses. In the levirate the
wife will marry her dead husband’s brother. Seventy percent of a sample of 159
societies reported on in Murdock’s (1965) classic cross-cultural correlational
study of traditional societies preferred this form, while 60 percent preferred
the sororate in which a man marries his dead wife’s sister. One explanation
of these practices suggests that remarriage between relatives is important for
maintaining the stability of the familial group, which may be threatened by the
death of the parent. Alliance theory argues that these marriage forms main-
tain alliances originally established by the dead sibling (Scupin, 2003: 75–76).
Marriage creates kinship relationships between individuals and groups. We
shall begin our discussion of kinship by focusing on descent groups. Descent
groups are characterized by a permanent set of relations that are not changed
by residence or death. These groups are formed through various principles
of descent and represent ways in which human groups organize themselves.
Descent is defined as “the cultural principle based on culturally recognized
parent-child connections that define the social categories to which people
belong” (Schultz and Lavenda, 1990: 261). Descent groups comprise people
who recognize shared ancestry. It is the primary way people are organized in
nonindustrial and prestate societies. Though nuclear families are defined by
common residence and are therefore impermanent, the descent group is per-
manent (Ferraro, 2004: 228) (Figure 10.1).
Although marriage seems to be a staple in the lives of many Americans,

some social groups have attempted to operate sans matrimony. Some exam-
ples of these institutions include communes, religious orders, and/or warrior
castes. The most well-known people in the United States practicing this
tradition are the Shakers. Since the 1700s, Shakers have coveted religion
over sexual unions, and have practiced communal living as well as celibacy.
In the 1840s, the Shaker movement reached its peak with more than 6,000
members, spanning from Florida to Maine in over twenty-five communi-
ties. Since they practice celibacy, the Shakers relied on the recruitment of
new members as their strategy for growth. After the Civil War, membership
in the Shaker community began to decline seriously. Today, only a small
community of believers remains in Sabbathday Lake, Maine (Foster, 1991;
Ponzetti, 2003; Robbins, 2006: 145–148).
Descent systems are either unilineal, tracing one’s ancestors through one side
of the family and not the other, or are non-unilineal. Non-unilineal descent
is also referred to as bilateral or cognatic descent and is based on the princi-
ple of tracing descent through both parents equally (Ferraro, 2004: 235–236).
Approximately 40 percent of the world’s societies are non-unilineal. These
include bilateral, ambilineal, and bilineal descent. The US descent system is
called the bilateral kindred.
Matrilineal descent traces membership through the female line only, while
patrilineal descent traces group membership through the male line only. In
these systems, an individual will trace ancestry through either their matrilin-
eage or patrilineage. Unlike the clan, the lineage has demonstrated descent in
that members can trace their kinship and exact relationships to one another
and a founding ancestor. In contrast, stipulated descent occurs among people
who claim to be related to a common ancestor but are unable to document the
exact relationship because the ancestor is either hypothetical or very remote.
Stipulated descent is associated with clans.
Hawaiian Kinship
Father Mother Mother Father Father Mother
Sister Brother Sister Brother Sister Ego Brother Sister Brother Sister Brother
Sudanese Kinship
Mother’s Brother Mother’s Sister Mother Father Father’s Brother Father’s Sister
Maternal Maternal Sister Ego Brother Paternal Paternal

Cross Cousins Parallel Cousins Parallel Cousins Cross Cousins
Inuit Kinship
Uncle Aunt Mother Father Uncle Aunt
Cousin Cousin Cousin Cousin Sister Ego Brother Cousin Cousin Cousin Cousin
Iroquois Kinship
Uncle Mother Mother Father Father Aunt
Cousin Cousin Sister Brother Sister Ego Brother Sister Brother Cousin Cousin
Crow Kinship
Cousin Cousin Sister Brother Sister Ego Brother Sister Brother Aunt Father
Omaha Kinship
Mother Uncle Sister Brother Sister Ego Brother Sister Brother Cousin Cousin
Figure 10.1 Kinship variations.

Note: Inuit is the contemporary preferred term used to describe the people referred to as “Eskimo”
on the kinship chart.
The Mosuo (also known as Moso, Nari, among other terms) ethnic group of
southwest China illustrates a society in which family is based on the principle
of matrilineal descent. The Mosuo are unique among China’s ethnic groups
who typically are patrilineal. Among the Mosuo, descent is traced and prop-
erty is inherited exclusively through women. Fathers have a peripheral role
in the lives of their children; in fact, the word “father” does not exist in the
Mosuo language nor are in-laws recognized as a category. Sons typically re-
side with their mothers. This kinship system creates a family that consists of
mothers, daughters/sisters, and sons/brothers. The Mosuo are indeed a society
in which women are in charge. This matrilineal system provides women with
a great deal of power, including selecting their lovers and claiming position
as the head of a household, the dabu (Mackie, 2005: 1–3; Yuan and Mitchell,
2000: 58–65).
Mosuo women and men practice a very loose system of relationships re-
ferred to as “walking marriage.” Although they are similar to the precolonial
Nayar in terms of matrilineal descent and visiting “husbands,” the Mosuo are
unique in their absence of any formal marriage practices at all. The Mosuo
system differs from the definition of marriage in that it is not contractual,
obligatory, or exclusive (Shih, 2001: 381). The Mosuo participate in a system
of visiting relationships between lovers. In the Mosuo language it is called
sisi, which translated means walking back and forth. The sisi arrangement is
also referred to as zou hun (walking marriage) or azhu huny (friend marriage).
In the sisi relationship men visit their lover at night but must return to their
mother’s home before breakfast where they reside and have responsibility.
At around age twelve, Mosuo women are given a rite of passage ceremony
and after puberty they can begin to receive male visitors. Children born of
these relationships live with the matrilineage. As is typical of matrilineages,
brothers have an important role to play in the lives of their sister’s children
both economically and socially. It is the matrilineal household that takes full
economic and social responsibility for children born to daughters and sisters.
Although fathers may be close to their offspring, they have no social or eco-
nomic obligations to their children and these relationships can be ended at
any time by the mother.
This form of household and relationships is preferred by the Mosuo who
note that one of the benefits of this system is there is no dowry or economic
relationship involved at all. According to Mosuo community members, this
means the relationships are based solely on love without any strings attached.
When couples are no longer happy, they can very easily terminate the rela-
tionship. The Mosuo maintain that with friend marriage there is very little
conflict and fighting, since couples can so easily terminate their relationships.
This family structure provides a large extended family to share the work, one
not found in neighboring neolocal households where the couple is responsible
for all the work (Mackie, 2005; Yuan and Mitchell, 2000: 58–65).
With the Cultural Revolution in China (1966–1976) the Mosuo were pres-
sured to change their way of life. They accommodated the Chinese demand
that they formally marry, with couples living matrilocally. However, at the
end of the Cultural Revolution, they returned to their friend marriage system.
Although still practiced today, the Mosou have recently become part of the
Chinese tourist industry, which has stimulated their economy and allowed
more people to be educated. In addition, as young women begin to marry out-
siders, as media and the Internet become more widespread and available, there
will undoubtedly be changes in this traditional pattern of kinship and mar-
riage (Mackie, 2005: 1–3; Yuan and Mitchell, 2000: 58–65).
The Kapauko Papuans of the central highlands of western New Guinea
provide an example of a patrilineal society. The male members of a patrilin-
eage can trace their decent through males to a common ancestor. These men
typically represent the male population of a village or several adjoining vil-
lages. They live together or nearby because of a residence rule that requires
patrilocality; that is, upon marriage they must remain in the village/household
of their father (see above discussion). When a son marries he brings his wife to
live in his village, in or near his father’s home, while daughters must leave their
natal villages. The members of a patrilineage are discouraged from hostility
toward one another, since they are regarded as relatives and affectionate and
friendly relations are encouraged. The Kapauku also belong to larger patrilin-
eal decent groups called clans and phratries. As members of a patriclan they
believe themselves to all be related through their father’s lineage, although
the specifics of this relationship are not necessarily known. The patrician, un-
like the lineage, does not share a common village/residence. Kapauku cannot
marry within the clan and must practice clan exogamy.
The Kapauku are also related patrilineally through a phratry that is com-
posed of two or more clans. The two clans of the Kapauku phratry believe
themselves to be related through a myth in which the original phratry, which
consisted of one clan, was bifurcated when conflict between two brothers oc-
curred. In the myth, the younger brother was ousted from the original clan
and founded a new one, thus creating a relationship between the two clans of
the phratry. Although members of the same clan cannot intermarry, members
of the same phratry may intermarry if they practice clan exogamy (i.e., the
married partners are from two different clans) (Ember, Ember, and Peregrine,
2005: 381).
Clans are groups whose membership is based on the principle of unilineal
descent. Clans are defined as a descent group who are affiliated through the
belief that they have a common ancestor, even if that ancestor cannot be di-
rectly traced. The ancestor may be a person or a mythical being. Consequently,
clans have greater size and generational depth than the lineage. While the lin-
eage is the smallest unit of unilineal descent and may be a part or a segment of a
clan, even larger groups may occur. People of Scottish ancestry in the American
South perpetuate ancient traditions of Scottish clan affiliation through the an-
nual Scottish Highland Games and Gatherings. Although by the early 1700s the
power of the Scottish clans had diminished, a Scottish revival reinvigorated clan
identity through the association of clans, surnames, and tartan patterns. These
games reproduce the blending of a traditional Southern emphasis on kin with
Scottish clan social identity (Ray, 2003: 252–256). When a society is divided
into two large kin groups, this is referred to as a moiety system. Phratries are
unilineal descent groups made up of more than two clans. Phratries are rather
rare in the ethnographic and ethnohistorical literature (Ferraro, 2004: 234).
Having discussed marriage and family forms, the organization of human groups
based on marriage and children, and affinal and consanguineal relationships, we
now turn to the subject of sexuality and kin.
Incest Taboos
Childhood sexuality, like adult sexual expression, is managed by culture. One
of the ways in which it is managed is through proscriptions against incest. The
incest taboo is cited as an example of a cultural universal, although there are
exceptions to the taboo. The incest taboo is defined as a “[u]niversal prohibi-
tion against marrying or mating with a close relative” (Kottak, 2002: 700). The
incest taboo refers to those family members that we in the United States call
the immediate family. In virtually every society, sex is prohibited between an
individual and her/his siblings, parents, and children. These people are termed
“primary relatives.” Anthropologists continue to debate the origin of the in-
cest taboo, since it is such a widely shared institution. As a consequence of this
debate a number of theories have emerged. We shall review several of the more
prominent perspectives. These perspectives span a long timeframe and cross
disciplines including biological, psychological, anthropological, and integra-
tive approaches. Meigs and Barlow argue that “[t]he incest taboo is to anthro-
pology what Shakespeare is to English literature—fundamental and classic”
(2002: 38). The study of the incest taboo emphasizes prohibitions rather than
the consequences of actual incest taboo violations (Patterson, 2005). In those
societies where sex was allowed within families such as the ancient Egyptians,
Hawaiians, and Incans, it was restricted to nobility who were considered gods
and above human laws (Ember, Ember, and Peregrine, 2005).
Psychoanalytic theories represent one kind of explanation about incest.
Perhaps the most famous psychoanalytic view of the incest taboo is Sigmund
Freud’s theory of the Oedipus complex. The Oedipal complex has had an im-
portant impact on early- to mid-twentieth-century anthropological reflection
on the subject, particularly in the anthropological school of thought known as
culture and personality. This subfield regarded personality as causal in shaping
culture’s more expressive aspects such as art, religion, and mythology. Not all
anthropologists agreed with Freud’s formulation. In fact, the anthropologist
Bronislaw Malinowski in 1927 challenged the view that the incest taboo was a
result of the existence of the Oedipus complex.
Freud’s theory of the Oedipus complex was derived from his work with
specifically western European clients. The Oedipus complex is represented as
one stage in the psychosexual development of a child. The first phase a child
experiences lasts from birth through one year of age and is the oral stage in
which the infant’s interests center on the mouth as a source of pleasure. Freud
regarded pleasure seeking in the human as a given, as instinctual. The anal
stage occurred at approximately two years of age. It is the period in which the
child achieves control of his/her bladder and anal sphincter and finds pleasure
in this sensation. However, toilet training can cause conflicts as the child’s
wishes may be controlled by external pressures such as toilet-training prac-
tices. The Oedipal phase, or phallic stage, is characterized by love, hate, envy,
and guilt, and occurs from about three to five years old. This is followed by a
period of latency, from about six to twelve years of age, when the sexuality of
the Oedipal phase is repressed. At puberty, interest in sexuality is reasserted.
Libido, or the desire for sex which Freud considered panhuman and natural,
underwent various expressions and repressions through these developmental
stages. Freud felt these stages were embedded in our human biology and were
universal. Freud’s theory of development is linked to his view that sexuality is
both a conscious and unconscious force throughout the life course. This was
an astonishing view in light of his Victorian milieu.
The Victorian era is named for the reign of Queen Victoria who ruled from
1837 to 1901. The Romantic period, which began around the 1800s, fed the
Victorian era. The Romantic era celebrated nature and the unspoiled. These
notions filtered into the Victorian period. At this time the concept of the
noble savage flourished, derived from anthropological reports of “exotic na-
tives” communing with nature in its unspoiled and pristine state. Middle-class
English children were also seen as having a nobility derived from purity. They
were viewed as yet unspoiled by civilization. As the industrial revolution gained
momentum, children “became the last symbols of purity in a world which was
seen as increasingly ugly” (Sommerville, 1990: 198). Children were glorified
during the Victorian era. In short, they were next to the angels in virtue.
While middle-class adult Victorians had to suppress their impulses in an era
where sexuality and sexual symbolism were not publicly expressed, children
represented innocence of desire. They were in a state of natural privilege as-
sociated with “childhood goodness” (Sommerville, 1990: 204). Sommerville
(1990: 209) has suggested that this view of children did not extend to the
United States during this same time period. Middle-class US perspectives of
children demanded competence and performance in contrast to British views
of children who “symbolize[d] the innocence which a severely repressed society
felt it had lost.”
Sigmund Freud’s work on childhood sexuality followed closely on the heels
of the Victorian period. In 1905 Freud published his Three Essays on the Theory
of Sexuality. Freud felt that human sexual energy, which he called libido, was
present at birth and that through the course of children’s development; this
energy became focused in different body zones during the different stages of
psycho-sexual maturation. This embodied a very different interpretation of
the child from the Victorian notions of innocence. For Freud, the infant was
charged with an undifferentiated sexual energy; that is, he or she could find
sexual pleasure in the entire body in the erotogenic zones. This is what Freud
meant when he referred to the infant as “polymorphously perverse.” Libido is
an energy rewarded by the “aim” of pleasure. The erotogenic zones were areas
of the body through which libido could be discharged. Freud emphasized these
in his stages of childhood.
The oral stage of development focused on the mouth area as the first zone
for pleasure. This is the pleasure the child derives from sucking and nursing.
The second zone emphasized the anus and was termed the anal stage of de-
velopment. This was the period where the child has learned to control her or
his bowels and finds pleasure in the process of evacuation. The third or phallic
stage actually refers to the phase when children, between three or four years of
age, explore their genital areas and find self-stimulation to be pleasurable. This
stage, which accented the genitals, also included the Oedipus complex, which
occurs around the ages of five or six. For boys, as will be discussed shortly,
the Oedipus complex is resolved out of fear of the father and identification
with him. The little girl conversely desires her father and resents her mother
(Appignanesi, 1979: 76–88; Gleitman, 1987: 352–353; Lindsey, 2005: 26–27).
The latency stage follows the Oedipal phase. This was the period from about
six years old to puberty when children, according to Freud, lost interest in sex.
This phase initiated the end of the four stages of infantile sexuality. It should
be remembered that sexual interests were seen as repressed, but not eliminated
from the psyches of children (Appignanesi, 1979: 92; Westheimer and Lopater,
2005: 424–425).
The Oedipal phase is the cornerstone of Freud’s theory of psychosexual de-
velopment. Freud named this after Oedipus, the tragic hero in a mythical story
of a man who married his mother unknowingly and, upon finding this out,
blinded himself as punishment. According to Freud, the young boy covets his
mother and regards his father as a rival for his mother’s affections. In contrast,
the young female desires her father and regards her mother as a competitor. Her
complex is called the Electra complex. In the Electra complex, the little girl
subconsciously desires sex with her father, which comes about as a consequence
of penis envy and a concomitant sense of inadequacy. These wishes of both
boys and girls cause the child to feel fear and guilt toward the same-sex parent.
The Oedipus and Electra complexes are resolved through renunciation of the
love object and identification with the same-sex parent (Gleitman, 1987: 351;
Lindsey, 2005: 26). The gender bias in Freud’s theory was clearly expressed when
he wrote: “It does little harm to a woman if she remains in her feminine Oedipus
attitude… She will in that case choose her husband for his paternal characteris-
tics and will be ready to recognize his authority” (in Sayers, 1986: 101).
To account for the Oedipus complex as universal, Freud turned to an evolu-
tionary explanation. From Freud’s perspective, the almost worldwide appear-
ance of the incest taboo could be viewed as a mechanism to prohibit that
which we desire. But from where did this taboo and desire arise? Freud ad-
dressed this in Totem and Tabu (1950 [1913]). At some early and unspecified
point in time, there existed a “primal horde” in which a father kept a harem
of women but expelled his male children. The expelled brothers colluded and
murdered their father and ate him so they could have sexual access to their
sisters and mothers. However, after their dastardly deed, they felt a great deal
of remorse. Out of respect for their slain father’s wishes, they renounced their
mothers and sisters. This was the beginning of the incest taboo, which prohib-
its sex and marriage between immediate blood relatives. Freud cited evidence
cross-culturally of the ritual totemic meal, which he interpreted as a symbolic
re-enactment of this original crime. To Freud, the totem animal represents
the father who is ritually eaten in commemoration of this event. According to
Freud, the consequences of this primal scene have been transmitted to all of
us through the collective unconscious, presumably somehow inherited (Freud,
1950 [1913]: 34; in Bock, 1988: 32–36; Lyons and Lyons, 2004: 107).
In response to Freud, Malinowski argued that the Oedipus complex was not
a cultural universal but was relative to the particular family structures found
in a given culture. Since Freud’s theory was based on middle-class western
European values with family constellations in which the father was the dom-
inant figure, Malinowski tested this theory in a situation in which the family
constellation was quite different, that of the Trobriand Islanders. He addressed
this in his book Sex and Repression in Savage Society (1961 [1927]). He reasoned
that different family structures would likely lead to different kinds of conscious
and unconscious conflicts in individuals (Brown, 1991: 32). As we have seen,
the Oedipus complex proposes that a young male child will desire his mother
and want to get rid of his father. As the child matures, this complex is then
outgrown.
But the Trobriand Islanders had a very different family structure. They were
a matrilineal society in which kinship was traced through the mother. In fact,
the Trobrianders believed that the procreator of a child was a dead kinswoman
of the mother. Although the mother was the primary authority figure, she had
a warm relationship with her children. In contrast to the European system
in which the father was the authority figure, the mother’s brother among the
Trobriand Islanders assumed the role of disciplinarian. He was also the person
from whom the child would inherit. In contrast, the father (like the Trobriand
mother) had a warm and affectionate relationship with his children.
In the Trobriand Islands, it was the mother’s brother who earned the boy’s
hostility; and it was his sister, not his mother, whom the boy desired. Trobri-
and children were subjected to a rigorous brother/sister incest avoidance rule
(taboo) at puberty (Bock, 1988; Brown, 1991). Unfortunately, the comparable
complex for women—the Electra complex—has been relatively unexplored.
The Electra complex “received much less attention from Freud and almost
none from Malinowski…” (Brown, 1991: 32). This is typical of the “unmark-
ing” and silence around women that occurs in patriarchal societies and which
is reflected in scientific theorizing. Despite this shortcoming,
Malinowski’s finding became “the cornerstone for the thesis propounded

by relativists of all persuasions”—anthropological and nonanthropologi-
cal, Freudian as well as anti-Freudian—that… the Oedipus complex… is
a product of Western institutions and, more particularly, of the Western
“patriarchal” family structure.
(Brown, 1991: 33)
Malinowski’s theory was a functionalist interpretation of the incest taboo that

focused on its role in the maintenance of society. For Malinowski, the incest
taboo was necessary to maintain order because, without it, confusion in posi-
tions and family statuses would occur.
Other anthropological thinking on the subject includes those theorists who
suggest a biological explanation, proposing that some sort of genetic avoidance
mechanism exists against inbreeding. Arguments are mustered on both sides
of this debate. One side argues that deleterious genes have greater opportunity
for expression in incestuous unions; the opposing side counters that genetic
cleansing can in fact occur through this very process leaving the familial line
healthier in the long run. We know evolution works upon genetic variation
and that variation is a very effective mechanism for coping with environmen-
tal changes. Breeding outside of the immediate family provides the genetic
variation upon which natural selection can act. Shepher (1983) has reviewed
the literature on the consequences of incestuous inbreeding in human pop-
ulations and has found that 42 percent of the offspring were non-viable (in
Brown, 1991: 123–124). “If the figures Shepher cites are even approximately
correct, mechanisms to avoid the cost of incest between close kin are quite
expectable” (Brown, 1991: 123).
Primatologists and evolutionary psychologists have recently argued that in-
cest avoidance is evolutionarily old behavior (Meigs and Barlow, 2002: 40).
The primate data suggests this. There is evidence that both male monkeys and
female apes emigrate from their natal groups thereby decreasing the potential
for incestuous matings (in Walter, 1990: 441). Those that oppose the biological
explanations and promote more culturological perspectives cite the evidence
of preferred marriage and incest regulations associated with parallel and cross-
cousin marriage in unilineal societies. The distinction between these sets of
first cousins is not one made by Euro-Americans. A parallel cousin is the child
of ego’s mother’s sister or father’s brother. A cross-cousin is the child of ego’s
mother’s brother or father’s sister (Kottak, 2002: 402).
In societies that prefer cross-cousin marriage, parallel cousins are regarded
as belonging to ego’s descent group and are seen as similar to one’s siblings.
They may even be referred to by the terminology for brother and/or sister. Be-
cause cross-cousins are not regarded as consanguineal relatives, incest prohibi-
tions apply only in the case of parallel cousins (Kottak, 2002: 402). While most
societies prohibit marriage with parallel cousins, marriage with cross-cousins is
the preferred form cross-culturally (Ember, Ember, and Peregrine, 2005: 362).
About 30 percent of the world’s societies have a system where cross cousins are
the preferred marriage partners (Cohen and Eames, 1982: 125; Kottak, 2002:
402). There are some societies, for example, among Middle Eastern groups,
that prefer parallel cousin marriage (Ferraro, 2004: 204).
At this point, the issue of exogamy is relevant. The incest taboo is defined
by avoidance of sex between primary family members; rules of exogamy refer
directly to marriage (Spradley and McCurdy, 1987: 91). Exogamy ensures the in-
cest taboo is observed by marrying people outside of the family of origin. Whole
groups of people may be excluded as potential partners if they fall into certain
relationships with “ego,” the person from whom one is tracing relationships.
The groups may be lineages, clans, moieties, or tribes. To clarify the issue, rules
of exogamy refer to marriage, but the incest taboo may be expanded to cover
a much wider range of prohibited individuals than just biological parents and
siblings. Marriage prohibitions can include people who are not consanguineal
relatives. Thus, exogamy may include incest prohibitions, but may also extend
much further to include prohibitions against marrying a particular kin or group-
ings of kin, or sanctions to marry outside a village(s) (Ember, Ember, and Pere-
grine, 2005: 360). The incest taboo propels the practice of exogamy by requiring
people to find marriage partners outside their own groups (Kottak, 2002: 406).
This is often discussed anthropologically as the extension of the incest taboo.
As we discussed earlier, sex and marriage with cross-cousins may be ac-

cepted or even preferred in unilineal descent societies, but sex with parallel
cousins may be considered incestuous. Another cultural pattern illustrating
that cultures vary in how they define which relatives are forbidden occurs
among the strictly patrilineal Lakher of Southeast Asia. In this society ego
may marry his mother’s daughter by a different father (his half-sister). In this
case of strict patrilineal rule, mothers are regarded more as an in-law than
not a relative, since a mother is not part of the same descent group as her
children. By virtue of this same principle, ego couldn’t marry his father’s
daughter (half-sister) from a second marriage because they are part of the
same patrilineal descent group (Kottak, 2002: 403).
Some anthropologists believe the incest taboo arose as a vehicle for estab-
lishing alliances outside the family. In fact, Edward Tylor’s adage “marry out
or die out” is one explanation for the origin of the taboo. According to Tylor,
the “hatreds and fears” associated with closed families forced people to extend
alliances to other families and therefore to build societies (Patterson, 2005;
Scupin, 2003: 75; Shapiro, 1958: 278). This explanation is typical of the func-
tionalist approach in anthropology which maintains that institutions exist to
fulfill needs. Other notable anthropologists such as Leslie White, George Peter
Murdock, and Levi-Strauss have explained the incest taboo along these same
lines with various refinements and additions, yet maintaining the theme of
alliance building. Such hypotheses have been critiqued as explaining rules for
marrying outside one’s group, but not necessarily incest taboos, a subtle but
important distinction (Scupin, 2003: 75).
In 1922, Edward Westermarck offered an explanation for the incest taboo
which argued that the taboo reflects an absence of sexual desire expressed in
people’s intrinsic “horror” of incest. Incest rules therefore exist for those who
have gone “awry” or deviated (Brown, 1991: 119). Westermarck felt that the
lack of erotic desire that people raised in proximity feel toward one another
was an evolved sentiment ingrained in the psyche through biology. This the-
ory is often summarized as “proximity breeds contempt.”
The Westermarck effect has garnered substantial support particularly as it
relates to sibling incest. Spiro (1965) and Fox’s (1962) analysis of Israeli kibbut-
zim marriage and Wolf’s study of marriage in China (1966, 1968, 1970) pro-
vide provocative evidence for this theory. Spiro found that children who were
raised together as cohorts on kibbutzim as part of social planning to reduce the
role of the nuclear family practiced sex and marriage avoidance of one another
as adults (in Brown, 1991: 120). Fox interpreted this as support of the Wester-
marck effect. He concluded that in societies in which children are raised with
close physical intimacy, they will not have sexual desires for one another; and
the incest taboo will be more like an afterthought since siblings will not desire
one another anyway. However, societies where siblings are raised in the absence
of physical intimacy are more likely to have strict taboos since desire will need
curbing. Fox’s hypothesis integrates a Freudian thrust not incorporated by Wes-
termarck (Brown, 1991: 120). Shepher’s 1971 and 1983 research on kibbutizm
marriages supports the finding of lessened sexual attraction to partners raised in
proximity. In a study of 211 kibbutzim, there were only 14 marriages of peers out
of 2,769 married couples (Meigs and Barlow, 2002: 39; Scupin, 2003).
Arthur Wolf’s investigation of marriage in China has intriguing implica-
tions for the Westermarck effect. Wolf studied two forms of marriage practiced
in a Chinese village in Taiwan (1966, 1968, 1970). The minor form of marriage
was one in which a girl was adopted into her future husband’s family at an
early age and raised as a member of the family. In the major form, marriage
took place in adulthood without any previous familial association between
the partners. Wolf (1970) suggested that wife adoption would lead to a sexual
aversion in the couple who was reared together. In comparing major and mi-
nor forms of marriage, he found that in the minor form there were 30 percent
fewer offspring, the divorce rate was 24.2 percent and extramarital relation-
ships were found in 33.1 percent of the marriages. In contrast, major marriages
had a 1.2 percent divorce rate and 11.3 percent rate of extramarital sex (Wolf,
1970: 503–515). This evidence strongly supports the contention that familiar-
ity leads to disinterest and even aversion.
This is by no means an exhaustive review of anthropological theories of the
origin of the incest taboo, but only highlights some of the more prominent
ones. The more recent theories on incest and its taboo integrate the work of
some of these earlier theorists. For example, bio-social approaches argue that
close attachment of father and daughters reduces the likelihood of incest oc-
curring later as a result of some biological process activated through the social
process of active father involvement in childrearing (Meigs and Barlow, 2002:
42; Parker and Parker, 1986; Roscoe, 1994). Meigs and Barlow (2002) argue
that a fruitful direction for research lies in the psychoanalytic direction. They
suggest exploring the possible relationship reported in the anthropological lit-
erature between trance/dance behaviors that are linked with spiritualist ec-
static religious experiences and the dissociative experiences of incest survivors.
The incest taboo may be explained by a convergence of several theoretical
positions discussed in this chapter.1 The incest taboo
• establishes alliances and extends peaceful relations beyond the group;

• facilitates social networks and trade;
• promotes genetic mixture; and
• preserves family roles, guarding against socially destructive conflict
(Kottak, 2002: 406; Meigs and Barlow, 2002: 40).
These theories are not necessarily mutually exclusive but could be regarded as
interactive. For example, “cultural learning and genetic transmission are not
mutually exclusive alternatives and may interact to produce incest avoidance
in ways that are complex and flexible” (Meigs and Barlow, 2002: 40). We would
add that the Westermarck effect of childhood proximity leading to lack of de-
sire could be added to this list as a vehicle of psychological conditioning. Thus,
the incest taboo is a consequence of what people would not want to do anyway
under certain conditions. Walter argues that in societies where children are
exposed to prohibitions that prevent the familiarity of the Westermarck effect,
then desire for the forbidden could arise. In such a case, the incest taboo would
operate as a mechanism to prevent incest (1990: 440).
Despite the universality of the incest taboo, the particular form, focus,
meaning, and response to it is extremely variable cross-culturally. This diver-
sity is especially apparent in the case of exogamy, in which the incest taboo is
extended. In spite of the near universality of the incest taboo, incest does oc-
cur. We have discussed the special situations of exceptions for elites. We want
to turn now to incest in the United States, which is primarily non-consensual
and involves victimization. This is because children and adolescents are not in
a position vis-á-vis their parents and older siblings to give informed consent.
It is difficult to get an accurate estimate of the incidence of incest. One of
the problems with assessing the incest statistics is that these are clouded by the
“false memory” controversy. Over the last twenty years a recovered-memory
movement in psychotherapy has flourished. Therapists report that victims of
incest/child abuse experienced amnesia about these events and only through
therapy was this sexual abuse “recovered” and discovered. Detractors argue
that therapists were leading or suggesting this to their clients, and that there
is little evidence that actual incest or sexual abuse occurred (Patterson, 2005:
note 1; Tyroler, 1996).
One report suggested that 250,000 children are victims of incest, with half
of these cases involving fathers and stepfathers (Kelly, 1990 [citing Russel,
1983]). Another suggests that as many as one in twenty women may be vic-
tims of father-daughter incest (Scupin, 2003: 77). Depending on the report
and the time period of the study, statistics for incest range from 4 percent in
Gebhard’s (1965) study to 27 percent in Hunt’s (1974) survey (in Francoeur,
2004c: 613) and 15 percent in the work of Becker and Coleman (1988, in
King et al., 1991: 380). Recent figures by the Bureau of Justice note that 27
percent of all child sexual assaults were by a family member (“Sexual Assault
of Young Children,” 2000). The Child Maltreatment Survey in 2017 found
that 91.6 percent of all child sexual assault victims were maltreated by one or
both parents: 40.8 percent were maltreated by the mother alone, and 21.5 per-
cent by the father (Child Maltreatment Survey, 2017: 25). Almost 30 percent
of the father-daughter incest cases in the United States include an alcoholic
father (Berger, 1993). It must be remembered that although a stepfather or step-
mother is not a biological parent, but a social parent, the severity in terms of
trauma may be the same for the victim. The victim has had a trusted parental
figure violate her or him.
The survivors of incest suffer a host of psychological problems and malad-
justments throughout the life course as a result of their experiences. These
include sexual acting out, sexual dysfunctions as adults, low self-esteem, self-
blame, and self-destructive behaviors. They may experience psychological
problems not unlike the Vietnam veterans who suffered post-traumatic stress
syndrome. In addition, Newman and Peterson report that women experience
anger that is specific, toward mothers and fathers (1996: 463–474).
Anthropologist Mark T. Erickson has been exploring the incidence of in-

cest using a model based on evolutionary psychology and medicine (1999).
He suggests that within contemporary societies, as the family unit be-
comes more fragile with weaker kinship attachments, incest is likely to
occur more frequently. In the cases of incest that do occur between father
and daughter, the father is usually a person who has been sexually abused
himself and has not developed close kinship and familial attachments
with his children. An extreme lack of nurturance and mutual bonding
between family members increases the likelihood of incest arising within
families. Erickson’s finding suggests that the incest avoidance biological
processes can be stunted and distorted, leading to tragic results in con-
temporary societies.
(Scupin, 2003: 77)
Incest should not be confused with children’s curiosity about their own gen-
italia and that of their siblings that occurs around two to three years of age.
Sexual violence between siblings is much more prevalent than child abuse
by both parents; suggestively, it is the most common form of abuse within
families (Kiselica and Morril-Richards, 2007: 1). Incest as reported between a
brother and sister is five times more likely than between a father and daughter
in the United States (Westheimer, 2000: 154; Westheimer and Lopater, 2005).
Despite these findings, father-daughter incest is more heavily researched and
sibling incest and assault is underreported (Caffaro and Conn-Caffaro, 2005:
609). Thirteen percent of all college-aged students had experienced some type
of sexual activity with a brother or sister. Four percent of these cases involved
full coitus, while most reports involved looking at and touching sibling geni-
tals (Westheimer, 2000: 154; Westheimer and Lopater, 2005). In terms of gen-
der differences between experiences of sibling sexual abuse, one study found
that out of a sample of 49 female and 24 male survivors of sibling incest and
assault, a sister was most likely to be abused by their brother (Caffaro and
Conn-Caffaro, 2005: 608). In one study by Finkelhor (1980), 15 percent of
the women and 10 percent of the men in a college population reported this
behavior with 75 percent brother-sister exploration and 25 percent same-sex
behavior. But even in such a benign sibling context, there is still the possibil-
ity for coercion and possible incestuous sexual abuse. Twenty-five percent of
this population, mostly women, were uncomfortable because force was used
(in Francoeur, 1991a: 111). Incest survivors are invariably the less powerful
person in such interactions. Generally, the survivor is not in a consensual
position because of differences in authority or because of actual or threatened
physical force.
The double standard of the industrialized society’s gender system is reflected
in the incest statistics in the United States. Boys’ sexual abuse tends to be per-
petrated by a stranger, while girls’ is much more likely to be by a relative (Baker
and King, 2004: 1235). According to Stark (1984), 85 percent of the incest vic-
tims are female with “only 20 percent of the sexual abuse of boys and 5 percent
of the sexual abuse of girls perpetrated by adult females” (in Kelly, 1990: 356).
Recent figures suggest that between 20 percent and 30 percent of girls are
abused by a relative with 4 percent involving father-daughter incest, but only
about 10 percent of boys are abused by a relative (Baker and King, 2004: 1234;
Herman and Hirschman, 1981). Of those children sexually abused, the Bureau
of Justice Statistics (2000) reports that nearly one-third of all male sexual as-
saults were by family members, whereas only 25.7 percent of female assaults
were by a relative. Remember that sexual assaults on females far exceed those
on men (Pereda et al., 2009: 333; Stoltenborgh et al., 2011: 11). The National
Violence Against Women survey found that women are 6.5 times more likely
to be raped by non-spouse relatives, 3.4 times more likely to be raped by ac-
quaintances, and 4.8 times more likely to be raped by strangers (Tjaden and
Thoennes, 2006: 23). The frequency of stepfathers engaging in sexual activity
with family members is unclear in current research. Baker and King (2004)
indicate that stepfathers are more likely than biological fathers to engage in
incest, but several studies have shown this is not the case (Greenberg et al.,
2005: 55; Langevin and Watson, 1988: 149). Stereotypes from the media and
folklore can play into negative expectations of stepparents (Claxton-Oldfield,
2008: 53; Claxton-Oldfield and Whitt, 2004: 32).
Statistically speaking, family members were more likely to abuse younger
children with about half the incest victims under age six (“Sexual Assault on
Young Children,” 2000). A 1994 national survey revealed that 12 percent of
men and 17 percent of women reported that they had been sexually touched
by an older person when they were children. The offender was reported as
typically being a family friend or relative as opposed to a stranger (Laumann
et al., 1994).
Children who are survivors of incest are in a disadvantaged position in re-
lationship to the abuser. One common response is “accommodation” in that
they may feel they have no other alternative. They may be conflicted by the
love and trust they feel for the biological or social parent. Or they may not
want to cause family problems by telling; very often they have been manip-
ulated or threatened with consequences if they do tell. Thus, the accommo-
dation strategy is one of serious denial. Researchers note that some survivors
have no direct memory of the incest as adults. Only through psychotherapy do
they become aware of the memories so long denied and hidden.
One aspect of father or stepfather incest is the purported acceptance of the
situation by the mother. In such cases, the mother is reported to default in her
role as spouse, and the daughter or stepdaughter takes the mother’s role in re-
lation to her father or stepfather. In such situations, the young female is doubly
injured in terms of betrayal of trust, both by her father/stepfather and by her
mother who tacitly allows the relationship. The mother, not usually overtly,
may permit it to go on because it is part of the family denial system. How-
ever, this is a very controversial theory and some researchers such as Chandler
(1982), Ward (1985), and Myer (1985) deny that the mother has any role at all
(in Francoeur, 1991a: 615; in Kelly, 1994: 356). Certainly, the degree of the
mother’s tacit involvement varies depending on the family dynamics.
The father’s role as perpetrator is more clearly identified. In fact, the sexu-
ally abusive father or stepfather follows a pattern in which gender inequality
is an important factor. The father is typically hypermasculine in his disregard
and respect for women and children. We may view him as oversubscribing to
his gender role. Another contributing cultural factor, which may also play a
part, includes the perpetrator’s valuing (sexual attraction to) women for their
youthfulness. Finkelhor (1984) has identified four cultural and psychological
factors that converge to place children at risk for sexual abuse by fathers or
stepfathers. These factors are embedded in a patriarchal system of masculinity
and include the following ideologies and values:
• In sexual relations men must dominate.

• Most emotional needs are regarded by men as sexual ones.
• There is an inability of men to identify with the needs of children.
• There is a belief in patriarchal privilege and prerogative and the special
rights of the father/stepfather within the within the family (see Phelan,
1986: 531–539).
Flores and Mattos’ (1998) study in Brazil identified several predisposing factors
for incest that bear further scrutiny in other settings. These are identified as
“problems of family structure, extreme poverty, mother’s incapacitating illness,

mental illness of the aggressor, extreme violence in the family structure, social
interaction difficulties, multiple victims, incest recurrence in the family, and
mental retardation in the victim” (in Westheimer and Lopater, 2005: 741).
Discussions of adult-child sexual contact, whether incestuous or non-
incestuous, are highly charged with emotion in the United States. Given our
cultural mores and values, much adult-child sexual contact very probably will
have negative consequences for the child. Current research is limited in its dis-
cussion of racial, ethnic, and cultural factors related to consequences of adult-
child sexual relations (Kenny and Mceachern, 2000: 908). The universality of
the negative consequences of adult-child sex for children in the United States
is questioned by some researchers (Nelson, 1989a, b).
In an intensely debated article, Nelson posits that it is important to learn if
every incestuous sexual experience is always negative for the child (in Maltz,
1989). Nelson offers several conditions that may mitigate the deleterious con-
sequences for the child. These include:
• an emotionally bonded non-sexual relationship between the individuals;

• sexual contact which occurs between people relatively close in age;
• an egalitarian relationship between the parties (1989).
Given these three variables, an incestuous relationship may not always result
in long-term emotional scarring and damage for the child.
Pat Whelehan has dealt with a small number of adult male and female in-
cest “survivors” over the past three years. Some of these individuals did ex-
perience extreme emotional damage with long-lasting negative consequences
relative to their self-esteem and romantic relationships with others. Three of
these individuals came through the experience intact. The difference is that
the three individuals who viewed their incest/adult-child sexual experience
positively were males who were not coerced and who had a positive non-sexual
relationship with their older sexual partners. (They “checked in” with the
author because they wondered if “something was wrong with them” because
they felt “okay” about their experiences and who they are currently as sexual
adults.) The other survivors fit the model of incest “survivor.” They are women
who were coerced and had hostile or non-bonded sexual relations with males
who were not only older, but in a position of authority over them. They ex-
perienced much emotional and psychological trauma from their earlier sexual
contact (Whelehan’s counseling files).
Although it is difficult to remain objective about this issue given our culture’s
view on adult-child and incestuous sexuality, it is important to do so in order to
help those individuals who have been traumatized to regain a positive sense of
self and sexuality. We need to know when such contact may or may not be harm-
ful and then consider the individual’s unique experience across this continuum.
Theories of Childhood Sexuality
Freud’s theories of childhood sexuality present a conflict model of develop-
ment. Each stage has its unique set of conflicts centered around the erotogenic
zones. Neo-Freudians such as Karen Horney (1885–1952) and Erich Fromm
(1900–1980) among others challenged the Freudian view that erotogenic
zones and stages of development are the key to understanding human behav-
ior. Rather than focusing on the zones, some neo-Freudians felt that the rela-
tionships people had with one another were primary. This represents a shift
from biology, libidinal energy, and erotogenic zones to social relations in un-
derstanding childhood development (Gleitman, 1987: 355–356).
Horney took issue with Freud on several specific points in his theory of
childhood sexuality. She contested Freud’s position that children did not rec-
ognize gender differences at birth by asserting that children knew “intuitively”
the differences because each gender had sensations of being penetrated and
penetrating. Horney brings a less male-biased view to the psychoanalytic sce-
nario of child development. She argues that both genders envy one another’s
genitalia. This is in contrast to the Freudian perspective which proposed that
women have penis envy, but men have no comparable womb envy. Later in
her career, she challenged the Freudian notion of the Oedipus complex. She
regarded the Oedipus complex as situationally derived from a particular kind
of family dynamics where emotional dependency of the child was combined
with self-centered and unresponsive parents (Sayers, 1986: 40).
Dr. Spock’s Baby and Child Care book has had a tremendous impact on
childrearing worldwide, spanning over fifty years and continuing past Dr.
Benjamin Spock’s death in 1998. His book has sold over 50 million cop-
ies (making it second in sales only to the Bible) and has been published
in thirty-nine languages (Spock and Needlman, 2004; The Doctor Spock
Company, 2004). Since 1945, Spock’s book has been revised to accommodate
changes in gender roles and family structure in the United States. As he
neared his eightieth birthday, Spock added a co-author in anticipation of the
need for a successor to carry on the tradition (1985). The most recent edition
of Dr. Spock’s Baby and Childcare, the tenth edition, was updated and revised
by Robert Needlman, MD, the vice president of Development and Behav-
ioral Pediatrics at The Dr. Spock Company. Some relevant areas of revision
include “cultural diversity and nontraditional family structures, children’s
learning and brain development, and coping with family stress” (The Doctor
Spock Company, 2019).
Dr. Spock passed away March 15, 1998, at the age of ninety-four. Spock’s
model of childhood development, like Freud’s whom he admired, was also
based on stages of development. For example, he notes that “[b]oys become ro-
mantic toward their mothers, girls toward their fathers” (Spock and Needlman,
2004: 165). For Spock, these feelings about wanting to marry the other gender
parent happen as between the ages of three and six years old. He regarded
such feelings as important for preparing the child for adult sexual attraction
and relations: stating “[w]e realize now that there is a childish kind of sexual
feeling at this period which is an essential part of normal development” (1985:
447). Later, he notes “these strong romantic attachments help children to grow
spiritually and to acquire wholesome feelings toward the opposite sex that
will later guide them into good marriages” (Spock and Needlman, 2004: 166).
Again, like Freud, Spock perceived that this attraction brought up sentiments
of rivalry, jealousy, and fear toward the same-sex parent. For Spock, the res-
olution follows as a natural process. “Nature expects that children by 6 or 7
will become quite discouraged about the possibility of having the parent all to
themselves” (Spock and Needlman, 2004: 167). This marks the end of this phase
of attachment which will be “repressed and outgrown” and which is succeeded
by an interest in other activities such as athletics, education, and same-sex peer
involvement (Spock and Needlman, 2004: 177; Spock and Rothenberg, 1985:
437). Spock is rather Freudian in that he regards these interests as caused by the
sublimation of sex that takes place from ages six until about twelve years of age.
Spock advises parents not to give in to their children’s feelings of rivalry by
refraining from overt affection with one another. It is important for children
to be confronted with the fact that they cannot ever marry the parent. Spock’s
account is obviously influenced by Freudian theory of the Oedipus complex
(1985: 437; Spock and Needlman, 2004: 167–168). However, Spock’s represen-
tation of Freud is much less sexually oriented around the pleasure principle.
For example, Spock regards the interest in sex that occurs between two-and-
one-half and three-and-one-half years of age as part of a much broader pattern
associated with the “why” stage of curiosity (1985: 451; Spock and Needlman,
2004: 169, 174–175). He regards this as part of children’s natural curiosity about
why the genders are different and where babies come from.
Cultural Relativism and Childhood Sexual Behavior

The messages many US children get from their parents are that sex is bad
and should be delayed until marriage and that love must precede sex. This
is part of a cultural “ideal of childhood sexual innocence…that children and
adolescents need legal protection from all sexual contact and, in some cases,
from sexual information and contraception as well” (Konker, 1992: 147; Weiss,
2004c: 1181). In addition, this message is frequently gender biased. The double
standard for male and female sexuality is patently apparent to the young child,
although it may not be to the parents (Darling and Hicks, 1982; Francoeur,
1991a: 107; Francoeur and Noonan, 2004). Notably, young boys cause their
parents less concern when they express an early interest in sex and romance
than do young girls who may be thought of as “precocious” (Kelly, 1990: 166).
This is evidence of the double standard applied at a very early age; a little boy’s
sexuality is far more acceptable than a little girl’s in the United States.
Evidence from a variety of sources verifies the childhood capacity for sexual
response. In males, in utero penile erections have been reported as early as
seventeen weeks. Orgasm in boys occurs as young as five months old, although
ejaculation is not possible until puberty (King, 2005; Kinsey, Pomeroy, and
Martin, 1948: 177). Orgasm is reported in girls as young as seven months old
(Bakwin, 1974; Calderone, 1985). The human physiological sexual response
function is clearly in place early in infancy. This should not be confused with
the meaning we give to that response in terms of adult sexuality. The child
is merely exploring her/his body and responding to pleasurable sensations.
Childhood capacity for sexual response and pleasure is part of our biological
heritage. It is experienced very differently from adult sexuality.
Although the classic work of Ford and Beach (1951) classified US society at
the time as a sex-negative culture, a more contemporary view might regard it
as sex ambiguous, rather than purely negative, since elements of the positive
coexist with the negative. Sex-negative aspects are evident in attitudes toward
childhood masturbation. Yet the evidence shows
[that children] [w]hen left alone… spontaneously explore their bodies,

their genitals and experience their developing sexual nature. Sex play
and exploration are major factors in a child’s development. Even when
discouraged or prohibited by adults… children manage to explore their
bodies and their sex organs.
(Francoeur, 1991a: 107)
Sexual curiosity is a normal part of childhood growth and development. It

is expressed in play activities and seems to be a component of learning one’s
sexual identity and who one is as a member of a gender category with regard
to body awareness (Spock and Needlman, 2004: 446–459; Weiss, 2004c: 1181).
Goldman and Goldman (1982) in a comparative study of children in
Austria, Sweden, England, and the United States found that US children were
less knowledgeable about sexuality than the others. This may reflect gener-
alized trends in North American socialization practices wherein most par-
ents respond negatively to children’s explorations of their genitals. Children’s
curiosity about sex continues but becomes less overt in reaction of parents’
negative reaction to sexual exploration (King, 2005: 299–301; Weiss, 2004c:
1184). It may even become worse in the future if widespread fear about AIDS
negatively impacts sexual practices, or if parents respond to fears about incest
by not expressing affection to their children.
In the industrialized society, children experience several stages in their sex-
ual development. From about two or three years of age, children express inter-
est in their own genitalia and engage in various kinds of sex play with other
children. The doctor-nurse game is a common one whose sexual connotation
is acknowledged. Masturbation is prevalent among three- to six-year-olds
(Konker, 1992: 148). According to Kinsey, Pomeroy, and Martin (1948, 1953),
by five years of age 10 percent of boys and 13 percent of girls will have experi-
enced some kind of sex play. Current research supports the age of five or six as
when children develop an erotic interest in the same or the other gender. This
age is confirmed by cross-cultural data where children may imitate copulatory
behaviors of adults in societies where sleeping arrangements allow children to
observe adult sexual relations (Weiss, 2005: 1183).
Although Freud argued for a period of sexual latency between the ages of
six and twelve, Weiss (2005c: 1183–1185) argues that research has countered
this with ample evidence of sex play during middle childhood. For exam-
ple, Borneman’s (1983) research on childhood sexuality along with that of
Goldman and Goldman (1982) has seriously challenged this view. These re-
searchers report a capacity for sexual response from infancy throughout the life
course. In preparation for the adolescent period, children develop affectionate
relationships with special friends during childhood. In industrialized societies,
where there exists a well-defined concept of romantic love and heterosexuality,
children also express romantic interests. Ninety percent of the children aged
nine to eleven years in one study reported having a boyfriend or girlfriend
(Broderick, 1972). Although this is the period cited by Freud as one of latency
and lack of interest in sexual partners, children continue to be increasingly
interested in sex as they approach puberty. US sexual norms shape an inverse
relationship between public expression and sex.
Children between the ages of six and eleven during the alleged latency pe-
riod are anything but disinterested in sex. Research has confirmed that during
this period children are actively involved in heterosocial interaction and love
relationships. Indeed, it is not premature to argue that with globalization and
an increasingly mediated society, an industrialized trend for decreasing age
norms for behaviors such as having a boyfriend or girlfriend, being in love, and
dating will occur. Specific frequencies of childhood socio-sexual responses are
difficult to ascertain because the specific research studies have major limita-
tions preventing generalization (i.e., they include small samples selected from
specific groups, and are based on volunteers recalling experiences from a de-
cade earlier) (Weiss, 2004c: 1183–1185).
In addition, as children become increasingly interested in sex, their public
expression of that interest in terms of self-exploration, play with others, and
questioning is generally suppressed, further inhibiting estimating frequencies
of socio-sexual play. While sexual interest increases, sexual expression de-
creases. The same may be said of same-gender sexual exploration and romantic
attachments. Generalized homophobia is presented at an early age and com-
pounds broader sex-negative trends children in the United States are exposed
to relatively early.
It must be pointed out that there is a great deal of variation in parenting
perspectives regarding sexuality from the extremely punitive to the permissive
in our pluralistic society. Children also learn sexual mores from peers and the
media as well. The consequences of these childhood experiences can have a
profound impact on sexuality later in life. Sex therapist Dagmar O’Connor
fears that concern over AIDS will give children the notion that “sex will kill”
and this will enhance an existing industrialized society’s trajectory of fear of
sexual feelings (Jackson, 1990: 184).
Noted sexologists (the late) John Money and Gertrude Williams challenge
deeply embedded industrialized values when they state “a childhood sexual
experience, such as being the partner of a relative or an older person, need not
necessarily affect the child adversely.” They state that “no matter how benign,
any adult-child interaction that may be constructed as even remotely sexual
qualifies, a priori, as traumatic and abusive.” According to Konker (1992: 148)
the evidence is unconvincing that adult and child sexual contact is inherently
deleterious. The research indicates that children’s short-term and long-term
reactions to adult-child sexual contact are heterogeneous, from negative and
traumatic to highly positive (Weiss, 2004c: 1183). Money cited the recent so-
cial trends toward sexual conservatism as potentially harmful (“Attacking the
Last Taboo,” 1990: 72). For example, funding has been curtailed for research
on sexually troubled children as a consequence of such concerns (Jackson,
1990: 186). A fear exists that the response to child abuse may have gone too
far. Adults may become uncomfortable expressing affection to children and
children may consequently be denied affection and touch, which is so import-
ant in their development and capacity for bonding.
It is with this caveat that we explore childhood sexuality cross-culturally.
Evidence from the more restrictive societies such as ours will be contrasted
with more liberal approaches to childhood sex. This research is situated during
the ethnographic present to suggest broad trends in human sexuality prior to
the massive changes wrought by globalization. The classification of societies
as restrictive, semi-restrictive, and permissive by Ford and Beach (1951) rep-
resents a continuum of sexual mores among traditional societies. This is not
to suggest that restrictive and permissive societies are “pure” types without
variation as we mentioned previously. Undoubtedly within this classification
scheme, there are necessarily mixed and contrasting cultural elements with
regard to sexual expression. However, Ford and Beach’s approach is nonethe-
less a useful tool for comparison and contrast in spite of its limitations in rec-
ognizing overlapping diversity. Some of our examples will include incidences
of adult-child sexual interaction. It must be remembered that relativism is
essential as well as an awareness that such interactions cannot be viewed
from an adult, industrialized perspective. These examples must be regarded as
contextually framed.
We will turn to Ford and Beach (1951: 178–192) to begin our review of the
cross-cultural correlational approach to childhood sexuality (see Chapter 1 for
discussion). Ford and Beach’s study of human sexuality employed the Human
Relations Area Files and relied on a sample of 190 societies, although the sam-
ple size fluctuated in relation to available information for particular questions
and hypotheses. The United States along with fourteen other societies, among
them the Ashanti, Dahomeans, Kwoma, Murngin, Manus, and Trukese, are
labeled as restrictive societies in that children are denied any form of sexual
expression at all. How children are sanctioned varies from reprimands around
masturbation to more extreme measures. For example, among the Kwoma of
New Guinea, a woman has the right to hit a boy’s penis with a stick if she
catches him with an erection. Ford and Beach note that sex-negative cul-
tures such as these maintain a similar attitude about sex education by keeping
sexual information away from children. As we shall see in our discussion of
adolescence, a society that is restrictive in terms of childhood sexual explora-
tion may not be so restrictive for adolescents, or may have a double standard
for females and males. Regardless, punishment and discipline does not stop
children from exploring their bodies. For example, Trukese children will play
at having intercourse, even though they will be punished with a whipping
if caught. Other groups in which children’s sexual expression occurs despite
negative sanctioning include Haitians, Manus, and Kwoma (Ford and Beach,
1951: 180–187).
Semi-restrictive societies are defined by Ford and Beach as those in which
there may be formal sanctions against sexual behavior, but these are not en-
forced or regarded with great concern. The Alorese have a formal restriction
against children’s sexual expression, but unless it is blatant, the adults will
overlook it in the case of older children (Ford and Beach, 1951: 187–188).
Permissive societies are those in which there is a liberal attitude about chil-
dren’s sexuality. These societies are also permissive about issues of sexual edu-
cation. Included among these are: Copper Inuit, Easter Islanders, Hopi, Ifugao,
Marquesans, Samoans, Lesu, Tikopia, Wogeo, and Yapese. The Ponapeans,
for example, give a full and detailed sexuality education to four- and five-year-
olds. In societies in which children have access to covert observations of adult
sexuality because of sleeping arrangements, this may serve as a form of sex
education. We are not suggesting that adults engage in sex publicly and in full
view of their children. One of the components of human sexuality, apart from
certain ritual situations, is its privacy. However, where families share a room
as among the Pukapukans, children will take advantage of the opportunity to
observe and to learn about sex, despite their parents’ efforts at discretion (Ford
and Beach, 1951: 188–192).
Among the non-restrictive societies are those in which adult-child sexual
interaction occurs. These are societies in which adults may stimulate the gen-
italia of children and include the Hopi, Siriono, the Kazak, and the Alorese
(Ford and Beach, 1951: 188). It must be remembered that this kind of stimu-
lation on the part of the adult cannot be understood from the perspective of
industrialized society’s adult sexuality. Such adult-to-child behavior occurs for
a variety of reasons. It may be done to calm the child down or give it pleasure,
not unlike the way in which an infant or child stimulates herself/himself. It
may also be considered part of the maturation and development of a child’s
sexual functioning. There is a great deal of heterogeneity in such practices and
the Lepcha of India provide an excellent example of a society that condones
childhood sexual expression. Because the Lepcha believe sexual intercourse is
important for stimulating maturation, eleven- and twelve-year-old girls engage
in full coitus. According to Ford and Beach, “Older men occasionally copulate
with girls as young as eight years of age. Instead of being regarded as a criminal
offense, such behavior is considered amusing by the Lepcha” (1951: 191). Other
cases of adult-child sexual interaction include finger defloration of female in-
fants among some Indonesian societies, “first” Australians, and Hindu Indian
groups. The Tontonac of Mexico invite a priest to deflower the infant girl
about a month after her birth, followed by the mother’s defloration of her six
years later. Among the Kubeo, an old man would deflower the eight-year-old
girl by stretching the vagina until three fingers could be inserted (Gregersen,
1994: 291). In fact, child-adult sexual contact is institutionalized as part of
initiation rituals in at least twenty countries (Konker, 1992: 148).
Such cultures are also permissive toward auto-stimulation or self-pleasuring
as well (i.e., masturbation). Societies that are tolerant of self-stimulation include
the Pukapukans and the Nama Hottentot in which public self-masturbation
by children is considered acceptable behavior. Other societies are indulgent
of children’s early efforts to imitate adult copulation. Trobriand children even
engage in oral and manual genital practices with no parental objections. As
children approach puberty different restrictions or proscriptions may be placed
upon them (Ford and Beach, 1951: 190–192). We shall discuss these later child-
hood experiences in greater depth in our discussion of adolescent sexuality in
Chapter 11.
The subject of cross-cultural childhood sexuality requires cultural relativism
and sensitivity. It is all too easy to allow our own ethnocentric attitudes about
sex to color our understanding of the cross-cultural record. Kelly (1990: 223)
has coined the term erotocentricity to define the process whereby we allow
our own culture’s sexual attitudes, values, and mores to bias our understanding
of sexuality in other cultures. Judith Levine cautions against views of child-
hood sex as pathological or high-risk behavior and argues that children should
be educated with the view that most sexual expression is normal and healthy
(in Weiss, 2004c: 1186). This will continue to be important as we discuss ado-
lescent and adult issues in sexuality. Relativism is vital not just with respect to
the cross-cultural record, but with regard to the variety of sexual experiences
and expressions found in complex industrialized societies.
Summary
1 Childhood and parenting were discussed.
2 The functions of marriage and the family were presented.
3 The subject of kinship was introduced along with kin terms, including
residence and descent.
4 Some of the major theories of incest were offered along with the conse-
quences of incest.
5 Theories of childhood sexuality were reviewed including the psychoana-
lytic perspective and Dr. Spock’s perspective on childhood sexuality.
6 Attention was given to childhood sexual expression in the United States
and cross-culturally.
1 How could cultural definitions of incest shape the way individuals actu-
ally experience and interpret sexual encounters with a culturally defined
family member?
2 As a child, do you recall participating in childhood sex play? If so, what
type of parental response did this invoke? Do you recall what messages you
received from society about this behavior? Did your behavior continue,
or did it become covert due to negative responses from parents and/or
society?
Suggested Resources
Books
Francoeur, Robert T. and Raymond J. Noonan. 2004. The Continuum Complete Inter-
national Encyclopedia of Sexuality. New York: Continuum.
Namu, Yang Erche and Christine Mathieu. 2003. Leaving Mother Lake: A Girlhood at
the Edge of the World. Boston, MA: Little, Brown and Company.
Website
US Department of Health and Human Services, Administration for Children and
Families, Administration on Children, Youth and Families, Children’s Bureau.
(2011). Child Maltreatment 2010. Available from http://www.acf.hhs.gov/programs/
cb/stats_research/index.htm#can.
Stages, Part II
Puberty and Adolescence
Chapter Overview
1 Defines and constructs puberty and adolescence.
2 Discusses rites of passage as initiation ceremonies that facilitate the tran-
sition to adulthood.
3 Presents the three phases of rites of passage.
4 Presents female genital cutting as a controversial issue in rites of passage.
5 Uses the Sambia as a case study of rites of passage in which older boys
orally inseminate younger boys.
6 Outlines adolescent sexual behavior in nonindustrialized as well as indus-
trialized societies.
7 Addresses the issue of adolescent sterility.
8 Reviews the topic of sex education in the United States.
9 Compares and contrasts adolescence in the United States with nonindus-
trialized transitions to adulthood.
Puberty and Adolescence: A Bio-Cultural Phenomenon

In the dominant, Anglo culture of the United States, remembering that the
United States is a plural society of culturally and ethnically diverse peoples,
adolescence or “the teen years” are considered a tumultuous time when young
people are trying to find their identities and places in both their culture and
adult society. The United States and other industrialized nations regard ad-
olescence as a distinct phase in the life course noted for its youthful turmoil
and rebellious behaviors (Mead, 1961 [1928]). In fact, it is this industrialized
culture-based view of adolescence as a life crisis that inspired researchers such
as Margaret Mead in the now classic Coming of Age in Samoa (1961 [1928]) to
explore the cross-cultural record to search for the alleged causes of teenage
trauma. Mead’s contribution to the study of adolescence has been discussed
in Chapter 1 and will be again later in this chapter; recall her argument that
the “storm and stress” of adolescence is shaped by culture rather than due to
raging hormones.
It should come as no surprise to learn that the ethnographic spectrum chal-
lenges such a narrow view of this period in young people’s lives. Adolescence
232 Puberty and Adolescence
is not universally regarded as a stressful period, nor is it considered by all
societies as a distinct phase in the life course. For the purposes of linguis-
tic convenience, we shall use the term “adolescence” to refer to the teenage
years, bearing in mind that it is not a cultural universal. Though people in the
United States and other industrialized nations generally utilize a life course
scheme that includes five phases – infancy, childhood, adolescence, youth, and
adulthood – other societies have far different views of how the life course may
be segmented. For example, indigenous peoples, according to Oswalt (1986:
99), “usually recognized few formal age groups, and by the time children were
eight years old, they were working for or with same sex adults.” In traditional
Aboriginal Australia, girls were promised to husbands before they were born
and married before menarche (in Ward, 2006: 72). Although nonindustrial
peoples do not elaborate the adolescent stage as do we, most of the world rec-
ognizes that the period of sexual maturation is one in which readiness for
adulthood occurs. With such a time-oriented culture as our own, we often
think of age in absolute terms, such as adolescence occurring with the teenage
years; yet it must be remembered that age is a relative concept that is best
understood as membership in a social category (Suggs and Miracle, 1993: 78).
Before continuing, it is appropriate here for us to define our terms since ad-
olescence is often confused with puberty. Puberty is generally defined biologi-
cally. It is the period in life when secondary sexual characteristics develop and
a person becomes capable of reproduction (Kelly, 1990: 512; Offir, 1982: 521;
Ward and Edelstein, 2006). Puberty usually takes from two to four years. In
girls, the ages for the onset of puberty are approximately nine to sixteen, and
in boys, from twelve or thirteen to fifteen or sixteen (Ford and Beach, 1951:
170–171; Goldenring, 2005). A detailed discussion of the physiology of puberty
has been described in Chapters 5 and 6. In females, menarche occurs at the
same time as the hips widen and about a year or two subsequent to the devel-
opment of breasts. Girls in the United States on the average reach menarche
around twelve years old, although the age at which this occurs is affected by
diet and nutrition (Spock and Needlman, 2004: 192–215). The cross-cultural
evidence suggests that females in nonindustrial societies are generally not fer-
tile following menarche (Ford and Beach, 1951: 172; Schlegel and Barry, 1991).
An increased interest in sex as a result of the physiological changes that hap-
pen with puberty is also reported (Byer and Shainberg, 1991: 375). However,
it must be reiterated that interest in sex is extremely variable in individuals
and is influenced by culture (Kelly, 1990: 167; King, 2005: 306; Spock and
Needlman, 2004: 446–464). How one experiences the biological baseline of
puberty is shaped by social structure, subsistence technologies, stratification,
kinship and descent, cultural values such as conservative or liberal attitudes
of parents, religious orientations, and a number of other factors (Schlegel and
Barry, 1991).
Menarche is one of the more obvious indicators of puberty. The onset of
menstruation has followed a historical trend of occurring at an increasingly
younger age. General changes in growth and development over the generations
Puberty and Adolescence 233
are referred to as a “secular trend.” In industrialized countries, menarche is
now reached two years earlier than it was in 1900 and four years earlier than
in 1840 (Moore et al., 1980: 138–139; see also Keizer-Schrama, de Muinch,
and Mul, 2001: 289). In nonindustrialized countries, the pattern for menarche
occurs at a younger age in urban areas than rural ones (Keizer-Schrama, de
Muinch, and Mul, 2001). Economic variables are also important. In higher
economic strata menarche begins earlier than in lower classes of the same
population (Moore et al., 1980: 140). Better nutrition and overall body fat
seem to be partly accountable for this change, and better health care, im-
provement in socio-economic status, along with genetic influences also con-
tribute to this phenomenon (in Keizer-Schrama, de Muinch, and Mul, 2001:
290; Moore et al., 1980: 140). More recent research by Herman-Giddens et al.
(1997) argues that features associated with puberty such as breast development
and pubic hair growth have occurred earlier, but that the average age for US
Caucasian girls’ menstruation has remained stable since the 1950s. Anderson
and Must (2005: 753–760) confirm this, noting that the average age at men-
arche in the United States declined by only 2.3 months between 1988–1994
and 1999–2002; by race/ethnicity declines were even smaller. From 2002 to
2015, the average age at menarche only changed slightly from 12.6 to 12.5
years of age (CDC, 2017). Non-Hispanic girls of color experience menarche
earlier than their white counterparts (Reagan et al., 2012: 8) A similar trend
was noted for British girls (“Girls Maturing Slightly Earlier,” 2001). Reasons
cited for the earlier development of secondary sexual characteristics are the
increase in obesity and exposure to environmental estrogens and other chem-
icals (Lydon, 2006). Hauspie, Vercauteren, and Susanne (1996) suggest that
this leveling off of age of menarche may be due to reversing of socio-economic
factors and/or due to genetic limits.
Although puberty is identified by a series of physical changes, adolescence
is a cultural construct defined as a “period of emotional, social and physical
transition from childhood to adulthood” (Goldenring, 2005; Kelly, 1990: 505).
For Anglo-Americans, adolescence is the time of life that spans puberty and
ends with adulthood. Spock and Needlman (2004) classify adolescence into
three phases: early adolescence from age twelve to fourteen, middle adoles-
cence from age fifteen to seventeen, and late adolescence from eighteen to
twenty-one. Each phase is characterized by its own unique psychological tasks.
Thus, early adolescence is a period focused on rapidly changing bodies and
feelings, middle adolescence emphasizes coming to terms with sexuality and
romantic feelings and the process of emotional separation from parents, while
late adolescence is focused on finding a career and developing longer-lasting
emotional relationships (Spock and Needlman, 2004: 203–211). Adolescents
report a variety of motivations for exploring casual sexual relationships with-
out the responsibilities of an emotional attachment to a partner; these include
physical gratification, emotional gratification, and initiation of a romantic re-
lationship with a partner (Garcia et al., 2012: 12). Adolescents in today’s day
and age are hitting puberty at a younger age and getting married later on in
life. It’s suggested that this gap has led to an increase in prevalence of hookups
among young adults (Garcia, 2008: 201). This is discussed in more detail in
Chapter 12. It is important to recognize, however, that adolescence is a social
category and is not limited to just the teenage years. This period of psychoso-
cial maturation may even extend into the late twenties in some societies such
as the United States and Ireland (Francoeur, 1991a: 41). Spock argues that late
adolescence may be extended even further into the early thirties for students
who enter graduate school straight from college and who may continue to
be supported by their parents. Thus, independent living may not occur until
relatively late prolonging late adolescence (Spock and Needlman, 2004: 210).
If adolescence is recognized as a distinct life stage in a society, how and
when it begins, as well as what it means, differ a great deal throughout the
ethnographic spectrum. In an industrialized society, adolescence as a separate
period in the life course has varied historically as well. Adolescence did not
appear in European culture until the nineteenth century. And it was not un-
til the 1800s that adolescence also came to be regarded as a time of conflict,
especially among upper-class youths. Prior to that time, youth was regarded
as a period of preparation for adulthood that covered a long time span with
gradually increasing responsibilities. There were various symbolic markers for
the transformation of youth into adulthood. This was related to the economic
situation in which working-class children at age ten or twelve years old en-
tered occupations, as apprentices for example, in the case of boys, or perhaps
as domestic servants in the case of girls. These decisions were made by their
parents.
Having entered upon their calling, children were playing parts in the
adult world and had a recognized status there, even though they were not
yet considered adults. Rights and responsibilities came gradually, with a
number of milestones on the way to maturity. In some respects they were
still considered children for years afterward. But the adult world was not a
foreign and unknown territory to them.
(Sommerville, 1990: 213)
Other options varied by class for girls and boys. Upper- and middle-class boys
were also involved with training for their profession by the latter part of their
teenage years. During this period, the age of marriage was around fifteen years
old, and puberty did not happen until much later—around eighteen or twenty
years old (Francoeur, 1991a, b).
The Industrial Revolution changed the nature of work and, consequently,
the apprenticeship as a mechanism to integrate youth into society was lost. As
the population grew so did employment opportunities for the middle and up-
per classes. Male aristocrats sought positions in the military and government
which, in turn, had to be expanded to accommodate their need for employ-
ment. At the same time, education for the upper and middle classes also kept
youngsters in the home under their parents’ guidance. The results of these
trends were the creation of adolescence as a separate phase in industrialized
youths’ lives characterized by their separation from the world of work and
adults (Sommerville, 1990: 216). Along with this trend, the age of puberty also
gradually dropped from the late teens and early twenties to what it is today
(Aries, 1962). This historical overview points to the importance of cultural
molding and varying context of adolescence as a life stage. Therefore, when
researchers such as DeLameter and Friedrich (2005) define pre-adolescence
as the years from eight to twelve and adolescence as spanning ages thirteen
through nineteen, this must be placed within the current context of early
twenty-first-century middle-class US perspectives, remembering that adoles-
cence is a social construction.
Turning to the cross-cultural data, we find that the most elemental ways
that peoples categorize and define themselves are based on two criteria: age
and gender. Adolescence is an example of an age grade. Age grades are a
social classification of people whose ages lie within a culturally distinguished
age range. As individuals progress through different age grades they acquire
different rights and obligations as their status changes (Cohen and Eames,
1982: 411; Scupin, 2003: 158). In many societies one’s age grade is a significant
part of one’s life and place in society. This is particularly true in non-stratified
societies in which other ways of identifying and categorizing individuals such
as on the basis of power, wealth, and status are absent.
The magnitude of age grading in people’s lives is related to age sets. An age
set is “[a] non-kin association in which individuals of the same age group inter-
act throughout their lives” (Oswalt, 1986: 432). This means a group of people
of the same gender and similar age will move together though the various life
stages of a particular society together. For example, among the Shavante of
Mato Grasso area of Brazil, boys of seven to twelve years of age are inducted
into the bachelor hut together where they begin a rite of passage wherein they
learn hunting, weapons making, and ceremonial skills, ultimately culminating
in adulthood and elder status. At the end of five years, the boys enter the age
stage of young men together where more learning occurs. After another five
years, the boys marry (in a group age set ceremony) their wives who have been
selected for them by their parents. After this ceremony they may sit on the vil-
lage council and are regarded as young warriors. The final stage for the age set
is a progressive one occurring at five-year intervals as each age set matures with
the eldest age set consisting of the senior men with the most authority. Al-
though Shavante women also have age sets, their participation is much more
limited and doesn’t include the initiation ceremonies, life in bachelor huts, or
elaborate ceremonials. In fact, their age set doesn’t really function as a same-
sex association for women as it does for the men. This may be because the
Shavante society is gender stratified to a certain degree; for example, women
are not allowed to sit on the council where community business is transacted.
Such a set of initiations and stages of increasing authority of Shavante men
provides them the opportunity to strengthen and validate cultural concep-
tions of masculine superiority and privilege in societies in which women have
less prestige and power (Ember, Ember, and Peregrine, 2005: 393–394). One of
the consequences of initiation ceremonies is to foster age sets among initiates.
The residents of Salem (old Salem today), of the Protestant Moravian

faith that came to the colonies from the present-day Germany, believed
in a system whereby people of a similar social status lived and worshipped
together, representing an historical example of U.S. age-grading system.
The community was divided into choirs, a Greek word for “group,” ac-
cording to age, sex, and marital status: married people, single sisters, single
brothers, widows, widowers, and children. Each choir had its own meet-
ings for religious instruction, its own festal days, and tasks for which it was
responsible. Some choirs lived together: there were dormitory-style houses
for single brothers and single sisters which children joined at the age of
fourteen and where they remained until marriage. Colored ribbons in fe-
males’ caps also indicated an age grade as well; a red ribbon for little girls,
pink for unmarried women, blue for those who are married, and white for
widows (Taylor 1988).
Puberty Rituals: Initiation Ceremonies as Rites of Passage

In many societies there occurs a “[c]eremonial recognition of a major change in
social status, one that will permanently alter a person’s relationship with mem-
bers of the greater community” (Oswalt, 1986: 437; also Nanda and Warms, 2004:
329). Such ceremonies are called rites of passage or a passage ceremony. Not
every society marks the transition from childhood to adulthood with elaborate
ceremonies. The United States is an example of a society that does not do this.
It has been proposed that this absence of rites of passage rituals is the cause
of much trauma in Anglo status transitions (Shapiro, 1979: 283), although the
converse may be argued as well. Rituals may actually increase stress and anxiety.
For example, Plains Indian boys/youths participated in a vision quest to find their
guardian spirit through altered states of consciousness promoted by isolation,
fasting, and ingesting hallucinogenic drugs (Kottak, 2004: 350–351). Rites of pas-
sage often include initiation ceremonies in which a child undergoes a transition
and transformation to the new status of adult. In 1909, Arnold Van Gennep orig-
inated the rites of passage model (rites de passage) as a tripartite scheme and ex-
plained the functions of these ceremonies. According to Van Gennep (1960: 3):
Transitions from group to group and from one social situation to the
next are looked on as implicit in the very fact of existence, as that a
man’s [and a woman’s] life comes to be made up of a succession of stages
with similar ends and beginnings: birth, social puberty, marriage, fa-
therhood and motherhood, advancement to higher class, occupational
specialization, and death. For every one of these events there are cere-
monies whose essential purpose is to enable the individual to pass from
one defined position to another which is equally well defined.
Rites of passage have three distinct phases: separation, transition, and incor-
poration (Van Gennep, 1960: 12). In separation, an individual is removed
from his/her previous world or place in society. Transition or liminality in-
volves “threshold” rites that prepare an individual “for his or her reunion with
society.” This is the phase in which the initiates undergo training for their
anticipated status. As part of this, they are likely to experience some sort of
ordeal or testing. Incorporation rites integrate the initiates back into their
society/social group. This includes a return to the community after the initiate
has been socially and perhaps even spatially removed. It is the public recogni-
tion of the person’s new status in society (Van Gennep, 1960: 21, 46, 67).
In the case of the pubescent, rites of passage function to ease the journey
from the status of child to that of adult. According to Chappel and Coon
(1942), changes of status are disturbing for personal and social relations within
the group. Initiation ceremonies, like other rites of passage, help ease and fa-
cilitate the transition to adulthood. They do this for the novice who must
experience an identity shift as he/she takes on a new position, as well as for
the broader social group who must now accept the youth as an adult. Initia-
tion rites are often stressful and include rigorous tests, hazing, isolation from
previous associates, and/or painful ordeals. These attributes provide symbolic
referents for learning about what the new status as adults includes. Adolescent
rites of passage provide an opportunity to practice and gain knowledge about
adulthood. Chappel and Coon (1942: 484–485) maintain that these ceremo-
nies restore equilibrium to the individual as well as the community. In addi-
tion, the dramatic, painful, and stressful elements may help prepare the youth
for the “stresses” of adulthood as well as function to enhance group solidarity
(Oswalt, 1986: 106). The rites of transition are particularly important as a pe-
riod in which the novice is liminal, or “betwixt and between statuses,” accord-
ing to Victor Turner (1969). By occupying this liminal status, the pubescent
individual will be in a unique position to unlearn her/his position as a child
and take on new responsibilities as an adult.
In summary, many societies provide rites of passage for adolescents to help
facilitate the transformation from the status of child to that of adult. As we
have seen, the transition to a new position in society may be marked by new
sets of rights and obligations as well as relations with people, including kin and
non-kin. It may include new expectations and changes in the individual’s iden-
tity as well. In preparation for this transformation, rites of passage participants
undergo a journey through three characteristic phases: separation, transition
or liminality, and integration. The phases of transition facilitate new learning
and the development of identity components necessary for the new status.
Ritual activities demarcate and actually facilitate the transformation of the
individual’s identity. They impress upon the novice the importance of the new
status and what it means to be an adult man or woman (or perhaps some other
option) in that society. By being separated socially and/or even geographically
from their families, novitiates are given an opportunity to develop themselves
as future adults. In addition, their families and others who have previously
related to them as children may now regard them in their new status as they
are reintegrated into society as adults. In such a way it is clear to the neo-adult
what their position and place in society will be.
There are, however, gender differences in rites of passage that may be re-
lated to variation in socialization. Chodorow (1974, 1989, 1995) has argued
that female and male socialization may be contrasted in terms of continu-
ity and discontinuity. She believes that this is based on the universality of
women as caregivers of children (i.e., the majority of children experience an
intimate relationship with a female, usually their mothers, during their early
years). However, there is a gender difference in the mother-child relationship.
Male socialization is discontinuous, in that boys must eventually experience
a separation from the domestic worlds of their mothers, while girls do not.
Young females learn to identify with their mothers and other women as associ-
ational role models and need not learn a new role as they mature. In contrast,
boys’ association with women during childhood prevents them from making
an easy transition into masculine role identification (Chodorow, 1974, 1989,
1995). Boys’ initial role model is a cross-sex one in contrast to the associational
one of little girls. This model has been critiqued as ethnocentric because it is
based on notions of the traditional nuclear family in which father is the bread-
winner and mother works in the home. Although it may apply to some white
middle-class Euro-American families, it does not necessarily apply to all; for
example, African American and Mexican-American families. Despite these
shortcomings, Chodorow’s work remains as a major contribution in feminist
psychoanalytic identification theory and psychological anthropology, and has
continued to promote debate (Renzetti and Curran, 2003).
Theories about why initiation ceremonies are often much more elaborate
and at times more severe for males than females, although female ceremonies
are more prevalent, may be related to Chodorow’s thesis. There are a number
of ideas on this subject. Burton and Whiting’s (1961) cross-sex identity hy-
pothesis suggests that young men in polygynous and patrilineal households
are more likely, for a variety of reasons, to acquire a cross-sex feminine gender
identity. In order to switch their cross-sex identification with their mothers to
that of men, a severe initiation ceremony is mandated. It is designed to impress
upon the boys that the world of men is more important and valued than that
of women. According to this theory, severe practices such as circumcision or
genital surgeries are guaranteed to catch the young man’s attention and to re-
verse the feminine cross-sex identity. An important facet of these ceremonies
is a mockery or “put down” of women which contributes to masculine self-
definition as “not feminine.” This argument has been criticized because the
alleged cross-sex identity is not demonstrated or verified by the researchers but
only speculated upon. Other less psychodynamically focused theories include
Young’s socio-cultural interpretation of initiation ceremonies.
Young’s (1965) research emphasized that the functions of rites of passage
varied by gender; male initiation ceremonies were designed to incorporate
men into the entire community, while female initiations integrated women
into domestic groups. Young postulated that this was related to the differential
roles and tasks that each sex was assigned in society: women were assigned
domestic roles and men public roles. For Young, male solidarity was an import-
ant feature overlooked by the psychoanalytic approaches of researchers such
as Burton and Whiting (Bock, 1988: 117). Solidarity was also a salient feature
for the female household as well. Young explained that female initiations were
less elaborate because the domestic sphere is more private and less extensive
as opposed to the public world of males (1965: 106). The domestic arena is also
a continuous and familiar one in that females are born into it and exposed
to information about their role as they are growing up. This was suggested in
Chodorow’s (1974, 1989, 1995) approach as well.
Female initiation ceremonies will often ritually mark menarche, when a girl
begins to menstruate. The timeframe in a girl’s life between menarche and
full adulthood is referred to as maidenhood. Maidenhood, a period in girl’s
life where she is prepared for adulthood, is co-terminously a phase when there
is also great deal of cultural interest in her behavior. Maidenhood is a social
construction (not a biological period) and the length of time it encompasses
varies (Ward and Edelstein, 2006: 72).
Menarche is an event that is regarded as a very important in many cultures,
signaling a girl’s sexual and/or reproductive maturity (Ward and Edelstein,
2006: 273). How a society responds to menarche is related to the broader cul-
tural context such as attitudes toward women in general, women’s positioning
in society compared to men, forms of social organization, and beliefs about
menstrual blood. For example, New Guinea highland groups are well known
for their view of menstrual blood as polluting. Menarche rituals are as varied
as there are cultures. In some groups, like the Gussii, a clitoridectomy, removal
of the clitoris, may be part of the ceremony acknowledging menarche (see
discussion of female genital cutting). In other societies such as the Tlingit, a
girl was confined for at least a year with a series of proscriptions around her be-
havior (she must not gaze at the sky or must scratch an itch only with a stone)
(Oswalt, 1986: 108–109). Among Andaman Islanders, according to Service
(1978: 60–61):
Once menarche is attained, a girl in this society is secluded in a hut for

several days. Her behavior is closely regulated by prescriptions concern-
ing bathing, posture, speaking, eating, and sleeping. Their personal name
used during childhood is replaced by one taken from a plant in bloom
during the ceremony and is retained until the next rite of passage (mar-
riage). A boy reaching puberty does not experience physical isolation but
is singled out by the occasion of an all-night dance held in his honor.
Scarification of his back and chest further emphasizes his coming change
in status. Dietary restrictions are enforced for a period of a year or more at
the end of which time the boy is given a new name.
The meanings of menstrual blood vary from “power” to “pollution” and may
be related to specific menstrual taboos. Menstrual taboos are cultural rules
defining contact with menstruating women. According to Ward and Edelstein
(2006: 71), “[t]here is no cross-cultural evidence that menstruation is every-
where considered unclean, that women uniformly feel shame or pain, or that
menstrual blood repulses men.” They argue that if early anthropologists and
others would have labeled the seclusion of women in menstrual “sanctuaries”
rather than “huts” we would have a very different prism for regarding this prac-
tice. Currently it is difficult to evaluate whether menstrual seclusion practices
suppressed women or invigorated them with rest and recreation in a woman-
only domain (Ward and Edelstein, 2006).
Schlegel and Barry’s (1980: 696–715) classic study of 186 societies found
that societies that emphasized female initiation ceremonies were more likely
to be gatherers and hunters. They suggested this was because reproduction
is important for foraging groups whose population density is low. Such cere-
monies among foragers emphasize the importance of the life-giving attributes
of women. In contrast, initiation rites in small-scale plant cultivators (like
non-intensive horticulturalists) emphasize equally both girls and boys. How-
ever, when rigid separation of the sexes is enforced during the rites of passage,
this accents the cultural importance of gender differentiation in such societies
(Schlegel and Barry, 1980: 712). In fact, this characteristic is not uncommon
in puberty rites in general. Despite variance in social organization, a general
feature of female initiations is that they are centered on fertility while male’s
initiations are focused on responsibility. In horticultural societies with both
male and female initiation ceremonies, same-sex bonding is an important
function of the initiation ceremonies where homosocial relations (same-sex)
are an integral part of such cultures (Schlegel and Barry, 1980: 712). Before
turning our attention to an extreme form of ritualized masculinity in which
boy-insemination rituals flourish among the Sambia (Herdt, 1981, 1984a, b,
1987, 2006, among others), we will turn our attention to the topic of female
genital cutting to highlight issues in rites of passage for women.
Female Genital Cutting

As discussed in Chapter 6 female genital surgery/cutting including circumci-
sion, removal of the prepuce and clitoridectomy, the removal of the glans or
shaft, has been practiced in both industrialized and nonindustrialized soci-
eties. These practices may be included as rites of passage or alternatively, as
in the United States as late as the 1930s, as “cures” for female masturbation,
“nymphomania,” and/or insanity. Embedded in practices of female genital
cutting are cultural beliefs that link women’s sexual behavior to their sexual/
reproductive structures.
Female genital cutting in nonindustrialized societies is categorized as fall-
ing into four types according to the World Health Organization (Gruenbaum,
2005). Clitoridectomy (Type I) is defined as partial or complete removal of
the clitoris. This is known by Muslims and others as “sunna circumcision” or
“sunna purification.” The practice of circumcision, in which the clitoral hood
is completely removed, is very rare, although partial removal is common. In
excision (Type II), the cutting includes removal of the prepuce, the entire cli-
toris, and partial or total removal of the labia minora. An even more extreme
form of genital cutting is infibulation (Type Ш), also referred to as “pharaonic
circumcision,” in which part or all of the external genitalia are excised. This
may include the prepuce, clitoris, labia minora, and all or part of the labia ma-
jora; in some forms the labia majora are left intact. The edges of the remain-
ing tissues are infibulated (i.e., held or sewn together with stitches or thorns).
As a consequence, the vulva has a smooth appearance with a small hole for
urination and menstrual blood. In order to give birth a midwife must make
an incision for passage of the baby. After childbirth, the midwife then must
re-infibulate the mother. The World Health Organization classifies as Type IV
the practices that include various modifications of the female genital area but
not removal of tissues. These include “pricking, piercing, incision, stretching
of the clitoris or labia, cauterization, cuts or scrapes of the genitalia, or the use
of harmful substances inserted into the vagina” (“Female Genital Mutilation,”
2000; Gruenbaum, 2005: 483). For example, men’s desire and valuing of “dry”
sex in some East African countries has prompted women to insert harmful
astringent agents into vagina to “dry” it out prior to intercourse (Gruenbaum,
2005; Walley, 2006). This classification is not meant to suggest that female
genital surgeries are a unitary phenomenon. The particular form of cutting/
surgery varies by socio-cultural context and historically.
Female genital cutting encompasses many forms both in industrialized and
nonindustrialized countries. Traditionally and historically female genital sur-
geries span various religions including Islam, Christianity, Falasha Judaism,
and various indigenous beliefs and ethnicities from Indonesia to the Middle
East and Africa. It is prevalent in the Middle East and Islamic Africa including
North African and sub-Saharan countries (Gruenbaum, 2005; Walley, 2006).
However, because of the immigration of peoples (to the United States/other
industrialized countries) who practice female genital cutting, it has become an
issue that Euro-American and other industrialized countries have had to ad-
dress. Female genital cutting was first brought to the attention of the popular
media in the early 1990s in France in several legal cases in which a circumciser
and parents were charged with child abuse, and in subsequent cases of women
seeking asylum in the United States in order to avoid genital surgeries in their
home countries (Walley, 2006). The age for cutting varies cross-culturally and
may include infants and or teens of fourteen to fifteen or even older for ex-
ample the Maasai. It is most commonly performed on girls four/five and eight/
nine years old (Badri, 2000; Gruenbaum, 2005). What does this controversial
practice mean? Certainly, this depends on the cultural context and the stance
of the observer and/or participant. For example, as we saw in Chapter 6 among
the Gbaya, a horticultural group in central Africa, removal of the glans clitoris
in pubescent girls is a rite of passage, a symbolic and real marker of her transi-
tion from girlhood to womanhood.
Before discussing both emic and etic explanations, we must be attentive to
issues of cultural relativism and respect. As we stated earlier in this chapter,
we have been sensitive to the politics of naming (identity politics) and have
made reference to female genital cutting, surgeries, and operations instead of
the terminology “female genital mutilation.” Walley (2006) argues against us-
ing the terminology of “circumcision” since it underplays the impact on sexual
functioning (i.e., the loss of feeling in genital tissues and resonates with male
circumcision, which has not been regarded as “mutilating”; also Gruenbaum,
2005: 482). In fact, Walley notes, even the act of naming itself is controversial.
Using terminology such as female cutting, surgeries, or operations (such as we
do in this chapter) implies a culturally relativistic stance while “mutilation”
denotes “moral outrage” (2006: 335). We have followed Gruenbaum’s (2005)
use of the terminology female genital cutting and/or surgery/operations, rather
than female genital mutilation as is commonly used by the World Health
Organization, the popular media and among various scholars including some
schools of Euro-American feminism. Gruenbaum (2005: 481) makes a cogent
argument against using the terminology of female genital mutilation:
[S]ince “mutilation” connotes intentional harm, its use is tantamount to

accusing the women who do it of harmful intent. Some people, even those
who favor stopping the practices, have been deeply offended by the term
FGM, arguing that it is not women’s intent to mutilate their daughters but
to give them proper, socially expected treatment. Their intent is simply
to “circumcise” or “purify.” The words commonly used for female genital
cutting in Arabic-speaking countries, tahur or tahra, means “purification,”
that is, the achievement of cleanliness through a ritual activity.
The politics of naming are closely articulated with the consequences of these
practices for girls and women and penetrate Euro-American and other indus-
trialized national discourses about human rights and cultural relativism. The
psychological, reproductive, sexual, and health consequences of this surgery on
women, their families and partners are part of heated debates (Lightfoot-Klein,
1989, 1990). As we stated earlier, female genital cutting is a highly charged
issue that is influenced by acculturation, immigration, emigration, and global-
ization. Issues of ethnocentrism, cultural relativism, and indigenous cultural
integrity are involved.
As of 2013, at least 200 million girls and women had undergone FGM and an es-
timated 3 million girls are at risk for undergoing FGM every year (UNICEF, 2013).
There are well-established negative health consequences of female genital cutting
including infertility, shock, hemorrhage, septicemia, retention of menstrual blood
and urine (hematocolpos) resulting in urinary tract infections and chronic pelvic
infections, and serious complications in childbirth. Sexual functioning may be
interfered with resulting in painful intercourse and loss of sexual response. In the
situation of infibulation, first intercourse may not only be painful but virtually
impossible (Gruenbaum, 2005; Klapper, 2006; Kopelman, 2002). Lightfoot-Klein
(1989) and Gruenbaum offer some opposing evidence regarding sexual function-
ing, arguing that many women maintain their capacity for sexual responsiveness
and are orgasmic even with infibulation. This may be related to the degree and
type of cutting, expertise of the midwife, barber, “surgeon,” as well as the nature
of the relationship with the partner (Gruenbaum, 2005: 483).
Women with type III FGM have a 31 percent increased risk of delivering
via cesarean section and a 69 percent increased risk of developing postpartum
hemorrhage. Risk of infant deaths born from mothers who have undergone
type III FGM increased by 55 percent (WHO, 2019: 3).
Joy Phumaphi, Assistant Director-General, Family and Community

Health, World Health Organization, argues that: “‘FGM’ is a practice
steeped in culture and tradition but it should not be allowed to carry on.
We must support communities in their efforts to abandon the practice
and to improve care for those who have undergone FGM. We must also
steadfastly resist the medicalization of FGM. WHO is totally opposed
to FGM being carried out by medical personnel.” (“New Study Shows
Female Genital Mutilation Exposes Women and Babies to Significant
Risk at Childbirth,” 2006).
Note the use of terminology of “FGM” in this statement. The emic and etic
explanations for this practice sometimes converge and sometimes don’t. Female
genital surgeries cross diverse religions and therefore are not ethically the result
of religious dictums, although people who support or denounce the practice may
offer religious reference. For example, the Qur’an does not require it, but various
interpretations of Islam and the Prophet Mohammed may be cited as justification
for acceptance or rejection of the practice (Gruenbaum, 2005). The emic reasons
given for female genital cutting can be summarized as falling into five categories:
1 meets a religious requirement.

2 preserves group identity (i.e., custom and tradition).
3 helps to maintain cleanliness and health.
4 preserves virginity and family honor and prevents immorality.
5 furthers marriage goals including greater sexual pleasure for men.
(Kopelman, 2002: 50–52; Ward and Edelstein, 2006)
This said, understanding the practice of genital surgery requires a context that
can complicate a discussion of the practice. For some, such as the Maasai of
Kenya, it is a rite of passage and occurs usually at marriage when a girl is
excised. After she is healed she is allowed to join her husband as a woman, no
longer a girl. Yet for others, genital surgery may be resisted as part of ethnic
identity or adopted as part of acculturation for an immigrant group such as
among the Zabarma and Hausa minorities in the Sudan (Gruenbaum, 2005).
For some peoples, the genital cutting is part of an aesthetic for smoothness
that is regarded as part of an ideology of beauty held by both men and women
(Gruenbaum, 2006; Ward and Edelstein, 2006). It is also articulated with be-
liefs that female genital cutting enhances male sexual response (Gruenbaum,
2006; Ward and Edelstein, 2006).
From an etic perspective, Boddy refers to such practices as well as the con-
comitant rules for women’s modesty and chastity as the “overdetermination
of women’s selfhood” (1989: 252). These are rules of conduct that are more
restrictive for women than for men. Such rules and the practice of genital cut-
ting are associated with patricentric and patriarchal societies in which males
are dominant. This is not to say that women may not have power in the do-
mestic sphere, but that men hold the power in the formal spheres of society
including the public, economic, and the political arenas. Genital surgery is
therefore embedded in women’s subordination and ideologies that support that
subordination. These may include notions that women are “essentially” sexu-
ally voracious and the genital cutting “tames” those tendencies along with the
belief that women are unclean and hence are purified by the practice (Badri,
2000; Gruenbaum, 2005; Kopelman, 2002: 52).
These are extremely difficult, emotionally charged behaviors not only
within cultures, but across cultures as well. Resolution will take a long time
to achieve because female genital surgery is a complicated issue. Reference to
female genital cutting as mutilation and torture are culturally insensitive ways
to approach this issue. The international reaction of industrialized nations to
“eliminate” the practice is not always welcomed. There is a growing response
of African and other international/indigenous women who wish to eliminate
genital surgeries or who wish to introduce less invasive and more symbolic
forms of the surgery (Mutisya, 2002; Ward and Edelstein, 2006). Such ap-
proaches recognize how complex this issue is and include respecting the sym-
bolic aspect of genital surgery as a rite of passage signaling a young woman’s
readiness for marriage (Gruenbaum, 2005; Mutisya, 2002; Ward and Edelstein,
2006). As we have seen there are agencies such as the World Health Organiza-
tion that are completely against the practice and/or individuals, such as Alice
Walker in her film Warrior Marks, who asserts an unequivocal anticultural
relativistic stance toward this issue (Ward and Edelstein, 2006). However, as
Ellen Gruenbaum cautions: “[T]he first step in changing anything is to under-
stand what it means to the people who do it. With more insight, we can better
understand why people have resisted widespread change and why some are
now pursuing change” (2005: 488). Those wishing to introduce change in this
practice such as grassroots and local women leaders as well as their supporters
argue that increasing women’s educational and economic opportunities is an
important part of the solution for change. In addition, young men must also
take a stance that resists the practice by not marrying women who are geni-
tally cut (Gruenbaum, 2005).
Others have suggested surrogate rites of passage that don’t involve cutting
(e.g., a Kenyan rural group created “Circumcision through Words,” an alter-
native rite for girls that involves seclusion and learning women’s specialized
knowledge [Reaves in Gruenbaum, 2005]). More controversial and illegal in
many industrialized nations, are alternatives that involve medical professionals
in the nicking/pricking of the clitoris (Mutisya, 2002). This is clearly a difficult
subject traversing human rights, justice, fairness, respect for difference, emic
and etic approaches, and avoidance of harm among others (Salmon, 2006).
Lest we take a position of moral superiority as industrialized women and
men, it is important to understand how our own societies intervene in girls’
and women’s bodies through diet, exercise regimes, and other techniques
that make women beautiful and sexually desirable, such as shaving the pu-
bic area, bikini waxing, labial piercing, and plastic surgeries including breast
implants and “vaginal rejuvenation surgeries.” Vaginal rejuvenation surgery,
also referred to as vaginoplasty, includes specific procedures to tighten a “loose
vagina” and to reduce the appearance of enlarged labia. These have been mar-
keted as enhancing sexual satisfaction and beautifying the appearance of the
genitals (CosmeticSurgery.com, 2006; Navarro, 2004: 8; “Vaginal Rejuvena-
tion Surgery,” 2003).
Male Insemination Rites
The Sambia
Gilbert Herdt’s study, The Sambia: Ritual, Sexuality, and Change in Papua New
Guinea (2006, first edition, 1987), describes the rites of passage of the Sambia
male children/adolescents as they pursue adulthood. What makes the Sambia
of particular interest is that their initiation into manhood involves an ex-
tended period of masculine insemination rites in which older boys orally in-
seminate younger boys. All males among the Sambia will have experienced the
roles of inseminatee/fellator and inseminator/fellatee with other men during
the course of their initiation and journey into manhood (see also Herdt, 1981,
1984a, b, 1988). Herdt notes that boy inseminating rites were once practiced
among fifty or sixty traditional (precontact) cultures in Melanesia (2006). Ac-
cording to Herdt this ritual is part of “culture specific initiation rites, secret
male cults, and small-scale patrilineal societies involved in rampant warfare
among men and sexual antagonism between men and women” (Herdt, 2006:
xvi). Herdt’s research began in 1974 and spanned more than thirty years and
involved over twelve research trips. Since beginning his research, the Sambia
have undergone tremendous change including the ending of warfare (six years
before Herdt’s arrival), the increasing influence of Christianity through mis-
sionization, the growing impact of the wage labor economy, and a concomitant
escalation in women’s status (Herdt, 2006). Although the following discussion
situates the Sambia in the ethnographic present of 1974, Herdt (2006: 154)
comments on some of the more recent and dramatic changes that have
occurred:
A sexual revolution has overtaken the Sambia. In the past decade or so, they
have undergone huge life-changing, culture-breaking, and culture-making
alterations in their sexuality—greater than anything we have experienced
in our civilization in such a short period of time—and much greater than
the so-called sexual revolution of the 1960s in the United States. To go
from absolute gender segregation and arranged marriages, with universal
ritual initiation that controlled sexual and gender development and im-
posed the radical practice of boy-insemination, to abandoning initiation,
seeing adolescent boys and girls kiss and hold hands in public, arranging
their own marriages, and building square houses with one bed for the
newlyweds, as the Sambia have done, is revolutionary.
The Sambia are a highland Papua, New Guinea, group characterized by war-
fare and male privilege. As is typical in groups like this, there is great disparity
in the status of men and women, with men being privileged and dominant.
At a prepubescent age, boys will leave their mothers and live in all-male club-
houses, where for the next seven years they will fellate the older males (teenag-
ers and men in their early twenties) who share the clubhouse with them. It is
only by swallowing the ejaculate of the older boys that a young boy can hope
to grow into manhood. Manhood is defined by semen, which is regarded as a
very powerful substance. Boys are believed to be born without semen so it is
important that a boy consume as much as possible in order to have an ample
supply. The obvious way to get this is by fellatio, or oral insemination. Semen
has a power known as jerungdu (Herdt, 1987: 101, 2006: 57). Jerungdu is de-
fined as “the principle of male strength, virility, and manliness associated with
semen and warrior prowess in Sambia culture” (Herdt, 2006: 167).
Like sexuality in general, there are rules and practices regulating homo-erotic
behavior. When a young man reaches about twenty-five years old, he is mar-
ried. However, he must remain attentive to preserving his supply of sacred
fluids, lest his spouse, who is regarded as potentially dangerous and polluting,
sap him of his strength and use up his semen during intercourse. Societies
like the Sambia are noted for female pollution avoidance rituals, which dra-
matize women’s social inequality to men. Female pollution avoidance rituals
may restrict menstruating women by confining them to a special structure (a
menstrual house). These rituals are based on beliefs that females are impure.
Avoidance of women and concepts of female impurity associated with the fe-
male menstrual cycle contribute to status inequalities and disparities between
the sexes (Herdt, 1987, 2006). Such rituals do not occur in societies in which
women share power with men but tend to be found in patrilineal societies and
societies in which women have lower prestige (Zelman, 1977: 714–733). Note
that this does not necessarily contradict Ward and Edelstein’s perspective that
such seclusion may indeed be a sanctuary for women and while it may be per-
sonally empowering, such practices according to cross-cultural research, do
reproduce the relations of inequality and apparently do not augment women’s
overall status. The critical variable in whether seclusion is oppressive or en-
hancing to women may be the patrilineal kinship system. Clearly more re-
search is needed on this subject.
The purpose of initiation among the Sambia is to make men out of boys.
Little boys inhabit the world of women and are dangerously contaminated by
it. As a result of this, they are regarded as not quite masculine. Masculinity
is not something that is seen as “naturally” occurring for Sambian boys and
men; jerungdu must be acquired as the source of masculinity. Consequently,
males have two major barriers in becoming masculine: in addition to the femi-
nization of young boys that is believed to occur through their close ties with
their mothers, there is also the problem that males cannot manufacture their
own semen. To make matters worse they can lose jerungdu through ejacula-
tion. The Sambia ritualized insemination initiation resolves this dilemma
of manhood. Fellatio is the means of acquiring an initial supply of semen.
The proof of the power of the initiation among the Sambia is that young
boys provide evidence that it works by becoming bigger, physically strong,
and assertive. In the end, the pre-initiated and feminized boy (polluted by
contact with his mother) has been remade into a fierce warrior (Herdt, 1987,
2006). Through the course of initiation the boys have learned the cultural
values associated with masculinity and with it the secrets of manhood hid-
den from Sambian women. For example, heterosexual coitus is particularly
dangerous for men since through it they can lose their power. Once the
initiates are past the stage of ingesting semen through fellatio, they must
learn secret lore on how to replenish their jerungdu by drinking a white tree
sap that can restore their power (Herdt, 1987, 2006).
The Sambia are a provocative example to contrast with our own industrial-
ized society’s concepts of manhood and sexuality. During most of the initiation
cycle the initiate is not permitted any heterosexual activity. In the early stages,
the boys act as the fellators and ingestors of semen which contains the power
to make them grow into manhood. The initiates are prohibited from mastur-
bation or anal sex as well. In other words, they have no sexual outlets other
than wet dreams. However, from about fifteen years of age through eighteen,
the boys enter the third stage of initiation when they become bachelors and
inserters rather than fellators. Their ability in the “inseminator” role proves:
that they are strong and have jerungdu, because their bodies are sexually
mature and have semen to “feed” to younger boys. They feel more mascu-
line than at any previous time in their lives. So the bachelors go through
a phase of intense sexual activity, a period of vigorous homoerotic activ-
ity and contacts, having one relationship after another with boys. Their
sexual behavior is primarily promiscuous, for the initiates are concerned
mostly with taking in semen, while the bachelors mainly desire sexual
release through domination of younger boys… Eventually Sambia adoles-
cent boys become more interested in females.
(Herdt, 1987: 162, 2006: 115)
The purpose of the boy insemination is to acquire semen so that the youths
may ultimately marry and achieve fatherhood. Around the age of seventeen,
the bachelors enter the fourth stage of initiation in which they are permitted
interaction with women. From the beginning of the initiation until the fourth
stage, they have not been in contact with women. In their late teens and early
twenties, the initiates go through a fifth stage of bisexuality as married men,
which is followed by a sixth stage of adulthood in which heterosexuality is
practiced (Herdt, 1987, 2006). This stage is associated with the birth of the
man’s first child. Thus, the birth of a child is the marker for full adulthood.
Adolescent Sexual Behavior in NonIndustrialized

Countries
The Sambia initiation ceremony provides an excellent example for begin-
ning our discussion of adolescent sexuality in nonindustrialized countries and
among indigenous peoples. As we have seen, the Sambian male’s first experi-
ences involving the genitalia are as fellators from about age seven through age
fourteen. At fifteen years old, they then move into a new stage (the third stage
in their initiation) where they can experience sexual outlets for the first time
(other than wet dreams). Prior to this they were prevented from doing so. In
this phase they become the bachelor recipients of fellatio. The inseminator
phase is a very pleasurable one for the bachelors. From about the ages of fifteen
to eighteen, the third stage in the initiation, there is no opportunity of inter-
action with females, although it is a period of vigorous sexual activity for the
bachelor inseminators. This is a phase in which males experience “profound
homoerotic pleasures” (Herdt, 2006: 115; Herdt and Stoller, 1989: 33). The
inseminator role moves with them as they take on a new status as newlyweds
in the fourth stage of their initiation (they do not cohabit with their wives)
but continue their behavior as inseminators with boys. It is not until the men
enter the fifth stage of initiation in their late teens and after their wives have
experienced menarche that they are allowed to have genital sex with their
wives (Herdt, 2006: 60, 119).
This case clearly points to the difference between sexual behavior and sex-
ual orientation. The Sambia initiation ceremony is an important vehicle for
sex education facilitating the young man’s transition to a heterosexual life-
style. The bachelor inseminator, whose primary sexual experience is homo-
erotic, is gradually shifted into the status of newlywed which allows him to
make the transition in sexuality by going through a bisexual phase. According
to Herdt: “[t]he customary first sexual intercourse between spouses is fellatio”
usually taking place in the late teens or early twenties (Herdt, 1987: 164, 2006:
117). Culturally shaped sexual practices help ease the male into his change of
lifestyle from bachelor inseminator to that of newlywed and married man. The
newlywed bride is given sexuality instruction during her menarche initiation
(at around the same time as the men’s fifth stage initiation). She is given di-
rection on how to dress in such a way that she resembles the young initiates in
appearance for her first sexual encounter with her husband. The bride covers
her breasts and wears a noseplug similar to that of the young males that are the
fellators. “The bride’s similarity to the boys in appearance and the fellatio she
performs on her husband, thus helps to provide an erotic bridge between the
homoerotic and heterosexual lifestyles” (Herdt, 1987: 165, 2006: 118). Herdt’s
research on the Sambia challenges clinical theories that early homosexual ex-
periences invariably lead to later adult homosexual behavior (Schlegel and
Barry, 1991: 109). In addition, Herdt’s work interrogates the very concept of
homosexuality as a Euro-American culture-bound social identity contextual-
ized in time and space, hence his use of the term boy-inseminating rites in
the second edition of his book rather than “institutionalized homosexuality”
(Herdt, 2006: xv).
The Sambia are a fascinating example of nonindustrialized sexuality as it is
experienced in adolescence and into young adulthood. Male-female relations
are part of a well-reported phenomenon of sex antagonism in this particular
area of New Guinea. Women are regarded as potentially dangerous because of
their ability to pollute and deplete men of their semen. Wives were acquired
by politically motivated and arranged marriages. Because they came from out-
side the group (exogamy), they can never be completely trusted. While the
arranged marriages may help create alliances, they are also potentially disrup-
tive because at any time the bride’s family might become enemies. Warfare
plays an integral part in Sambia homoerotic as well as heterosexual behaviors
(Herdt and Stoller, 1989: 32). Keep in mind that our concepts of homoerotic,
bisexual, and heterosexual are in the context of our industrialized experience.
The Sambia do not have categories analogous to ours. Their heterosexual,
homoerotic, and bisexual behavior is obviously vastly different from the in-
dustrialized one and cannot be translated into our industrialized clinical and
homophobic perspective (Francoeur and Noonan, 2004: 814; Herdt, 2006: xv,
xxii; Herdt and Stoller, 1989: 31–34; Olive-Miller, 2004).
Turning now to our more general topic of pubescent and adolescent sexu-
ality cross-culturally, we need to point out that young men and women may
experience sexuality at different ages. For example, among the Tiwi, adoles-
cent women have sex with post-adolescent men, not men of their own ages
(Hart, Pilling, and Goodale, 1988). Age of marriage is an important variable to
consider since sex may occur in the context of premarital, marital, and/or ex-
tramarital sexual behavior. In countries in which individuals marry late, such
as Singapore where women marry at 24.4 years old, the premarital sex period
may extend into the twenties. Many of the studies of premarital sex in indus-
trializing nations target students as the research population so the ages may
span both teens as well as the early twenties. Conversely, marital sex may also
include the pubescent age groups since in many societies people who marry in
their teens may be regarded as adults. Marriage in most traditional societies
ends adolescence as a cultural stage (Schlegel and Barry, 1991: 109). In 74 per-
cent of forty societies, males marry at eighteen years or older and in 69 percent
of forty-five societies females marry at seventeen or younger. Cross-culturally,
the modal age of male marriage is eighteen to twenty-one years old and for
females it is twelve to fifteen years old. Men tend to be older than their wives
at first marriage, and hence experience premarital rules for a longer period of
time. However, it is important to remember that males generally have greater
access to a double standard that allows them more premarital sexual freedom
(Frayser, 1985: 208; Lewin, 2006: 10; Ward and Edelstein, 2006).
The meaning premarital sex has for industrialized countries is not neces-
sarily convergent with that in other societies. The cross-cultural research may
also have embedded ethnocentric assumptions. For example, data from the
Human Relations Area Files biases the definition of premarital sex by focusing
on heterosexual penile-vaginal intercourse. The degree to which premarital
sex among youths is approved of, disapproved of, and even condemned will
vary cross-culturally as well. Despite the diversity, all cultures have rules re-
garding sexual relations with appropriate partners. A variety of factors interact
and are related to these rules surrounding premarital sex. Societal approval
of premarital sex is related to the type of social organization, population den-
sity, subsistence, and resource patterns, all of which are directly related to the
status of women (Ember, Ember, and Peregrine, 2005; Manderson, Bennett,
and Sheldrake, 1999; Martin and Voorhies, 1975). However, sexual attitudes
and behaviors are not static, and vary over time and within populations by
ethnicity, generation, and class as a result of culture contact, or culture change
brought on by colonialism, missionization, escalating capitalism, and global-
ization (Herdt, 1999; Mascia-Lees and Black, 2000). Relevant also to this dis-
cussion is the role of adolescent sterility and cultural attitudes toward children
conceived outside marriage. Sexuality and its cultural regulation are related
to gender statuses and are rooted within specific social-structural systems, cul-
tural and temporal context as well as articulated with symbols and meanings
(Manderson, Bennett, and Sheldrake, 1999).
Although the HIV/AIDS epidemic has amplified anthropological interest in
how youths experience their sexuality from the subjective to the ethnographic
and the international (Herdt, 1999), Ford and Beach’s (1951), classic work in
the codification of cultures as restrictive and permissive based on a massive
review of 190 different societies continues to provide us with a useful approach
in describing adolescent sexuality. Their cross-cultural perspective has been
refined and continues to be an important source for understanding how and
why adolescent sexuality is structured. Most notable in this genre is the work
of Schlegel and Barry (1991) discussed later in this chapter. Again, this model
of ideal types represents what in actuality is a continuum. Ford and Beach
recorded fourteen very restrictive societies in which children are prevented
from sexual expression and acquiring sexual knowledge. However, sex with
the onset of puberty is allowed for girls in ten restrictive societies, and for boys
in one: the Haitians. “For the most part these peoples seem particularly con-
cerned with the pre-pubescent girl, believing that intercourse before menarche
may be injurious to her” (Ford and Beach, 1951: 18). In the majority of the
African societies studied by Ford and Beach, boys were prevented from having
sex before their initiation ceremonies. In some societies rules against sex after
puberty may remain restricted or may actually be intensified. To restrict pre-
marital sex among young people, societies will:
• separate the sexes;

• chaperone females; and/or
• negatively sanction premarital sex.
(Ford and Beach, 1951: 182)
Of these measures the first is the most successful, while the third has not
proven to be a deterrent to the highly motivated youngster (Ford and Beach,
1951: 183–184). One of the means restrictive societies use to ensure control of
youngsters’ sexuality is by placing a value on female virginity. Some may even
have tests of this virginity through demonstrations of bloodied cloth or deflo-
ration ceremonies (Ford and Beach, 1951: 186, also Delaney, 1991).
Virginity testing has been initiated among the KwaZulu-Natal in South

Africa as a way to prevent HIV. Virginity testing of girls from six years
old to marriageable age is supported by mothers and grandmothers to
prevent and curb “sexual licentiousness.” External genital exams and in-
spections are publicly performed by village women who use the same la-
tex glove for each exam, and who then grade the girls on their degree of
virginity. Girls who “pass” are cheered and given a certificate; girls who
“fail” are publicly shamed. Anthropologist Suzanne LeClerc-Madlala
notes that this practice, while not traditional to the group in its pres-
ent form, upholds deeply held patriarchal views about women’s worth
and sexuality among the Zulu. LeClerc-Madlala discusses the potential
health risks, false sense of security that derive from passing the exam,
the double standards about sex, and the culturally-structured beliefs
about female sexuality that exist among this group. Boys are not tested
since “they wouldn’t come anyway,” and “are like animals; they can’t
control themselves” (LeClerc-Madlala, 2001: 457). These practices can
foster the spread of HIV since they reinforce larger view about disease,
blame, and women as vectors of transmission” (Whelehan 2009:142).
In semi-restrictive societies, there may be formal proscriptions directed at teen-

age premarital sex, but these are not regarded as serious offenses. Prohibitions
against premarital sex for females specifically occur in twelve societies, for older
children in two, while sanctions against both sexes are found in thirty-four
societies (Ford and Beach, 1951: 187). Forty-three societies are classified as per-
missive in which there are no gender-specific restrictions on premarital sexual
expression; the only restrictions regarding sexuality are those around incest,
which would be expected (Ford and Beach, 1951: 190). Of these forty-three so-
cieties, there are three permissive societies that allow coitus for adolescent boys
only, the Crow, Siriono, and Tongans; one society that allows premarital permis-
siveness for girls only, the Thonga (Africa); and one that limits permissiveness
to the commoner class, the Nauruans. According to Ford and Beach (1951: 190):
[b]y the time of puberty in most of these [permissive] societies expressions

of sexuality on the part of older children consist predominantly of the ac-
cepted adult form of heterosexual intercourse, the pattern which they will
continue to follow throughout their sexually active years of life.
(Ford and Beach, 1951: 190)
Though Ford and Beach documented the variation in adolescent sexuality,

other anthropologists have been interested in explanations, asking questions
such as how social structure influences premarital sex norms. Schlegel and
Barry’s Adolescence: An Anthropological Inquiry (1991) continues to be a valu-
able compass in this regard. A summary of some of their findings and review
of the research is presented to illustrate how socio-cultural features pattern
sexual behavior (Schlegel and Barry, 1991: 109–121).
• For both sexes, adolescent permissiveness is related to the absence of a

double standard.
• Adultery for women and men is frequent in societies that are permissive
for adolescent sexuality.
• Premarital sexual permissiveness for females is associated with simpler
subsistence technologies, absence of stratification, smaller communities,
matrilineal descent, matrilocal residence, absence of belief in high gods,
absence of bride’s wealth, high female economic contribution, little or no
property exchange at marriage, and ascribed rather than achieved status,
an evaluation of girls’ position as equal or higher than boys’.
As mentioned earlier, concern for HIV/AIDS has resulted in an increase in re-

search on the subject of sex, including sexual behavior among youths in coun-
tries such as Thailand, the Philippines, Taiwan, Hong Kong, Sri Lanka, Japan,
Malaysia, Micronesia, and Melanesia (Bennett, 1999; Manderson, Bennett, and
Sheldrake, 1999; Sittitrai, 1990: 173–190). These countries have experienced a
growth in the transmission of AIDS from other areas through immigration and
tourism (see Chapter 16). Unfortunately, our industrialized heteroerotic bias
has focused primarily on male populations and heterosexual behavior (Sittitrai,
1990: 177). However, contemporary research is countering this bias.
Globally, men tend to over report sexual activity and women tend to under-
report (Wellings et al., 2006. According to the WHO, single men and women
in African countries report less sexual activity than in industrialized countries
(Wellings et al. 2006). Women report first experiences of sexual activity during
adolescence in West African, South African, Latin American, and Caribbean
countries; specifically, the youngest median age at first intercourse is in Mozam-
bique at 16.1 years old. Men have sexual intercourse earlier than women in Latin
America and Caribbean countries, whereas women have intercourse at a later
age in West African countries (MacQuarrie, Mallick, and Allen, 2017: 19).
Globally, adolescent girls who have been sexually active are more likely to
have been married than boys of the same age (Morris et al., 2015: 2). In many
developing nations young women in their teenage years are married; very of-
ten this is a result of arranged marriages (Cohen, 2004: 1). Though marriage
is valued and brings social rewards in virtually all societies, teen marriages are
known to be unstable. Rates vary considerably internationally; this practice is
most prevalent in western Africa such as in Cameroon and Mali, although it
is also pronounced in several other countries including Bangladesh, Mozam-
bique, Nicaragua, and Uganda. It is estimated that over the past decade, one
in three women in developing countries was married before the age of eighteen
(PRB, 2011: 1). At least half of all women aged twenty to twenty-four in nine
countries were married before the age of eighteen. Over 70 percent of women
in Niger, Chad, and Mali married before the age of 18 (Clifton and Frost, 2011:
4). These young women are not in a position to negotiate sex and contracep-
tives or HIV/STI prevention strategies with their husbands who may be older
and have more power in the relationship. Consequently, they are more at risk
for sexual violence, and their health and their child’s may be compromised by
early pregnancy (Cohen, 2004; Mathur, Greene, and Malhotra, 2003). Ac-
cording to Mathur, Greene, and Malhotra in the 2003 International Center for
Research on Women Report “Too Young to Wed: The Lives, Rights and Health
of Young Married Girls” the practice of marrying girls at or near puberty occurs
for two reasons: (1) to maximize fertility in cultures with high mortality rates,
and (2) to cement kinship alliances for social, political, or economic ends.
Mathur, Greene, and Malhotra (2003) suggest that incorporating data from
both figures provides a more accurate view of teenage marriage, and attention
to the diversity within the various regions must also be taken into consider-
ation. Current public health initiatives recognize regional and cultural diver-
sity in sexual behavior, particularly as it relates to age at first intercourse, age
at marriage, and contraceptive use (United Nations et al., 2015: 2; Wellings
et al., 2006: 2). Early marriage for women is an important issue for policymak-
ers in developing nations since such practices reinforce women’s lower status
by preventing them from pursuing educational and occupational training that
will help economically empower them (Cohen, 2004; Mathur, Greene, and
Malhotra, 2003). While early marriage is endemic to some regions, overall the
average age at marriage has increased along with the prevalence of premarital
sex (WHO Sexual Behavior in a Global Context: 2).
There are some studies available on adolescent sexuality that include homo-
sexual and/or bisexual behaviors and experiences. Most of the cross-cultural
and international studies of adolescent homosexuality/bisexuality do not fo-
cus on the specifics of homoerotic sex practices and meanings among youth
but emphasize self-reports of sexual attraction and interest and/or statistics on
same-sex encounters. One report suggests that 9 million people in the United
States identify as LGBT (Gates, 2011: 1). Around 8 percent of teens aged eigh-
teen to nineteen identify as homosexual or bisexual. Results from the Youth
Risk Behavior Survey of 2007–2017 indicated that LGBTQ teens in the United
States are more likely to have ever had sex than their heterosexual counter-
parts, and they are less likely to use condoms or birth control (CDC, 2017: 60).
It is well documented that LGBTQ teens face higher risks for STDs and sexual
violence as well (Hafeez, 2017: 2; Johns, 2019: 68; CDC, 2017: 2) Specific trends
in sexual activity in LGBTQ populations vary depending on ethnicity, race,
and socio-economic status (McGarrity, 2014: 389; USTS, 2015: 14).
For example, a study of adolescents in nine Caribbean countries spearheaded
by the Pan American Health Organization and the WHO Collaborating Cen-
tre in Adolescent Health at the University of Minnesota represents one of
the few comprehensive studies of youth health including sexual health in the
Caribbean. This study asked adolescents about same-sex attraction (WHO
Collaborating Centre on Adolescence Health, 2000). However, social norms
make discussion of same-sex behavior/bisexuality difficult for young people.
This study details the following findings:
• 4.5 percent of females under eighteen and 5.5 percent of males under eigh-
teen acknowledge same-sex attraction only.
• Five percent of girls under eighteen and 2.3 percent of males under eigh-
teen reported equal attraction to both sexes.
• 44.7 percent of the girls and 56.8 percent of boys report other sex attraction
with the remainder either uncertain, or not understanding the question.
Same-sex attraction is apparently reported anecdotally as becoming more

prevalent in Caribbean adolescent social circles. Sexual tourism is also a factor
in perceived escalation of same-sex behaviors as well. However, these were an-
ecdotal reports; actual data on same-sex experiences were not provided in this
research (WHO Collaborating Centre on Adolescence Health, 2000: 16–17).
In this regard Herdt (1999) has argued that much work remains to be done in
the study of the intersection of the individual and culture in homoerotic and
bisexual experiences.
The Continuum Complete International Encyclopedia of Sexuality (Francoeur
and Noonan, 2004) offers a stunning collection of sexual data from fifty-eight
countries, spanning both industrialized and nonindustrialized nations includ-
ing information on heterosexual adolescent sexual behavior, as well as specific
discussion of homoerotic, homosexual/lesbian, and bisexual behavior. Unfor-
tunately, information on adolescent homosexuality/bisexuality is not available
from all the countries surveyed; for example, Turkey (Aydun and Gulcut, 2004:
1065) and Nepal (Schroeder, 2004: 719). The data may also be very general,
depending on the country. In the Czech Republic, for example, it is noted
that 10 percent of the men and 5 percent of the women in the heterosexual
population had reported same-sex experiences in childhood and early adoles-
cence (Zverina, 2004: 323), while for Nigeria, the authors comment that the
incidence of same-sex sexual behavior for adolescence is very low (Esiet, 2004:
765). With enhanced international interest in HIV, STIs, adolescent sexual
health, and the importance of cultural sensitivity in sexual health education,
we can anticipate more specific information on adolescent homoerotic, homo-
sexual and bisexual experience and the meanings given to the experience in
nonindustrialized and industrializing nations.
However, a Japanese study offers unique insight into the specific erotic ex-
periences of adolescents and provides a useful model for the kinds of research
needed. Sittitrai (1990) reported 7 percent of the male and 4 percent of the
female research population experienced some male or female homosexual be-
havior such as kissing, petting, and/or mutual masturbation. These researchers
did note that the age of the first same-sex experience was fifteen to seventeen
years old with partners usually older (Sittitrai, 1990: 178). A recent study of
three national surveys in Britain identified an increase in diversity of sexual
experiences among sixteen- to twenty-four-year-olds: specifically, the study
showed increases in prevalence of anal and oral sex, and increases in number
of partners and same-sex relations between women over the past decade (Lewis
et al., 2017: 701).
These kinds of targeted data are essential for understanding adolescent sex-
uality, particularly as it relates to STI and HIV transmission. A great deal of re-
search remains to be done in this area. Schlegel and Barry (1991) have made a
substantial contribution in this regard and remain a valuable resource for their
comparative data on same-sex and bisexual sexuality. Using the cross-cultural
correlational approach, they compared same-sex behavior among pubescent
boys and girls in twenty-four societies. They found “[i]n virtually all cases, if
homosexual relations are tolerated or permitted for one sex they are for the
other as well.” In addition, their research indicates that cross-culturally, homo-
sexuality in adolescence tends to be transient and “appears to be a substitute
for heterosexual intercourse when intercourse is prohibited or access to girls is
problematic” (Schlegel and Barry, 1991: 126).
Adolescent Sexual Behavior in Industrialized Countries

In dominant US Anglo society, adolescence is commonly considered a period
of anxiety. It has been linked with a capitalist ideology of competition and
gender stratification as well as that peculiarly industrialized view of person-
hood as one of autonomy and independence. Industrialized adolescents may
well wonder if they measure up. Both males and females at this time expe-
rience concerns over adequacy; males are worried about their penis size and
females are worried about the size of their breasts. This is tied to their newly
developing sense of self as sexual beings. While there is no relationship be-
tween breast or penis size and one’s capacity for sexual functioning, these
myths prevail.
We would like to point out that the data on industrialized adolescent sex-
uality are biased toward the white middle class and do not typically include
variation by class and ethnicity. In addition, we are citing general patterns
and trends, not stereotyping or assuming that these features are true for every-
one. Generally, adolescent males or females are socialized differently in regard
to human sexuality and their respective roles in the process. Both sexes may
encounter increased sexual interest as a result of the physiological changes
accompanying puberty. Sexuality is an integral component in the dual gender
system of socialization. Males learn that they are the initiators of sex, that this
is a reward that they will, in all likelihood, have to work for in some way. Be-
cause they are the initiators, they also face the risks of sexual rejection.
Females learn that they are the keepers of a desired resource, sex. They are
not the direct sexual initiators, although frequently they are the initiators of
courtship through non-verbal actions and displays (Kilmartin, 2007; Perper,
1985). Adolescent sexuality is related to broader conceptions of gender ideol-
ogies. Young females are taught that once a male begins the process of sexual
arousal there may be no stopping him. So adolescent girls are warned not
to tease a boy and get him sexually excited. In addition, sexual experiences
for adolescent females are connected to intimacy needs, relationships, and
love. Adolescent female sexuality is not centered on orgasm or the genitalia
in contrast to adolescent boys’ sexuality with its genital focus and emphasis on
physical gratification (Hyde, 1985: 290; Westheimer and Lopater, 2005). Simon
and Gagnon (1973) refer to this as a relational ideology in comparison to a
recreational ideology (in DeLameter, 1989: 46). Reiss has referred to this as
permissiveness with affection (i.e., premarital sex is acceptable if the couples
have a bonded interpersonal relationship) (Reiss, 1980). This is embedded in
a sexual double standard that incorporates gendered assumptions about the
relative sexual experience and expertise of women in comparison to men as
well as expectations about experience and its meanings (i.e., women are more
culturally circumscribed in their sexuality than men).
The sexual double standard refers to an ideology that encourages boys to
experience their sexuality (i.e., allows boys to sow their wild oats), while girls
are socially sanctioned for the same behavior (Renzetti and Curran, 2003: 171).
There is compelling evidence that the double standard still exists (Hyde and
Jafee, 2000), although it has begun declining and/or shifting toward an af-
fectional model since the 1970s (Weiss, 2004: 1187; Westheimer and Lopater,
2005). Sexuality is a developmental process in industrialized society; over
time, female sexuality develops a more genital component and co-terminously
male sexuality may mature into a “more complex, diffuse sensuous experience”
much like that of the adolescent female (Hyde, 1985: 290; also Kimmel, 2000:
241). In this manner, as people age in industrialized society, their sexuality
becomes more alike than different.
Adolescent sexuality in the industrialized society includes masturbation
as a component, as it does cross-culturally. A male’s first ejaculation is usu-
ally experienced during masturbation. Kinsey, Pomeroy, and Martin’s (1948)
research reported that in 5 percent of the cases with male masturbation during
homosexual/homosocial activity, and in 12 percent of the population as a wet
dream. Generally, the rate of female masturbation is somewhat lower than
males as is their sexual activity in general, both homosexual and heterosexual
(Kinsey et al., 1953). Trends in female masturbation vary across the world:
65 percent of Portuguese women masturbate for sexual pleasure, 32 percent
to cope with stress, and 20 percent to aid in sleep (Carvalheira and Leal,
2013: 357). In a sample of eighteen- to twenty-five-year-old Croatian women,
around 50 percent reported having never masturbated (Baćaka and Śtulhofer,
2011: 252). One study found that male adolescents reported masturbating
more than females (73.8 percent vs. 48.1 percent, respectively), and that fre-
quency of masturbation increased with age. The sample was ethnically and
socio-economically representative of the population; Hispanic males reported
a higher percentage of masturbation than all other ethnic groups (Robbins
et al., 2011: 1). According to Robert T. Francoeur, there are a number of weak-
nesses and challenges in current autoerotic behavior research conducted in
the United States. These include the absence of recent data on non-college
men and women; the prevalence of small sample sizes; very limited or no data
on African Americans or other ethnic groups; and lack of funding for research
(Francoeur and Noonan, 2004: 1178).
It is difficult to acquire reliable information about masturbation rates in the
United States and other industrialized nations. Adolescent sexual experimen-
tation also includes the custom of making out, enhanced by the car culture
of the 1950s and 1960s. Making out usually refers to kissing, but it also may
escalate into petting. Commonly referred to as “hooking up,” a term used to
describe casual intimate behavior that occurs outside a closed relationship,
the negotiation of sexual behaviors between teenagers has shifted dramatically
in today’s adolescent population. Motivations for hooking up varies: approxi-
mately 50 percent of college students seek hookups for physical pleasure, while
the other half pursue them for the potential to form a committed relationship
(Heldman and Wade, 2010: 325).
Women are less likely to report positive experiences with hooking up; how-
ever, men and women are equally as likely to pursue hookups (Owen et al.,
2010: 653). Women can have a more difficult time managing social stigma of
hooking up due to the belief that women are entitled to satisfaction in a com-
mitted relationship, but not in casual hookups (Armstrong, 2012: 458). See
Chapter 12 on more about hookup culture.
Petting includes everything up to and short of vaginal intercourse, including
oral and manual practices. Through petting, adolescents learn to negotiate cul-
tural rules against vaginal intercourse by discovering alternatives that lead to
orgasm. For example, in a study by Newcomer and Udry (1985), 25 percent of
the males and 15 percent of the females in a population who had no previous
experience with heterosexual coitus engaged in oral-genital practices. Another
survey conducted in 2003 by Hollander shows that out of 580 ninth graders
in two California high schools, 20 percent of the students were reported as
having experienced oral sex whereas 14 percent reported having engaged in
penile-vaginal intercourse (Hollander, 2005). The alarming part of this study
was that 13–14 percent of the students were unaware that chlamydia and HIV
were contractible from oral sex. Thirty-eight percent felt that the chances of
chlamydia and HIV infection through oral sex were lower than those associated
with vaginal sex; and only 50–53 percent perceived that chlamydia and HIV
could be transmitted through vaginal sex (Hollander, 2005). Another discov-
ery is that these ninth graders acknowledged lower percentages of relationship
deterioration, development of bad reputations, getting into trouble, and feelings
of guilt associated with oral sex (36–63 percent) than with penile-vaginal in-
tercourse (42–71 percent) (Hollander, 2005). This suggests that oral sex is now
becoming more socially acceptable among US teens. A 2007 study suggests
that oral sex is common among adolescents regardless of their virginity status,
but that it is practiced less in adolescent populations that attend religious ser-
vices (Brewster and Tillman, 2008a: 78). According to the 2007–2010 National
Survey of Family Growth, 66 percent of women and 65 percent of men aged
fifteen to twenty-four years had ever had oral sex (Copen, 2012: 8).
Adolescents also engage in homosexual and heterosexual intercourse.
Kinsey and colleagues’ statistics, although dated (1948, 1953), are reveal-
ing considering the timeframe. Sixty percent of the males and 33 percent
of the females reported at least one homosexual or lesbian experience by
fifteen years old. These data again support the highly flexible nature of our
sexuality and the distinction between behavior and orientation. Studies in
industrialized nations reveal that teen sexual activity has fluctuated depend-
ing on the time period and the industrialized nation under consideration.
Two periods of increases in US premarital sex have been identified; the
“Roaring Twenties” from 1918 to 1930 whose sexual revolution corresponds
with women born after 1900 having premarital sex with their fiancés; and
1965–1980, a second sexual revolution with generalized increases in premar-
ital sex (Weiss, 2004a: 1187). Subsequent reports in the eighties substantiate
a continuation of this trend. For example, a study of women aged fifteen to
forty-four years old (n = 8,000) by the Alan Guttmacher Institute found
that female teen sexual activity, especially in Caucasian middle and upper
classes, was on the increase in the 1980s. They cite the following findings
(in “Teen Sexual Activity Rises,” 1991: 25) for this period in the United
States:
• The percentage of girls aged fifteen to nineteen who reported engaging

in sexual activities increased from 47.1 percent in 1982 to 52.25 percent
in 1988.
• The percentage of sexually active girls in the fifteen- to seventeen-year-old
age bracket rose from 32.6 percent to 38.4 percent in the same period.
• In 1986, 58 percent of sexually active teenage girls reported having had
two or more sex partners.
• In 1982, 48 percent of the sexually active girls aged fifteen to nineteen
reported that contraceptives were used in their first sexual intercourse.
• In 1988, 65 percent of the girls fifteen to nineteen reported that contra-
ceptives, mostly condoms, were used in their first sexual intercourse (Alan
Guttmacher Institute).
According to the Youth Risk Behavior Survey in 2017, 39.5 percent of high
school students in the United States had ever had sex: 41.4 percent were male
and 37.7 percent were female. The number of students who ever had sex has for
the most part steadily declined over the years (CDC, 2017: 10, see Figure 11.1).
72
64
56
PERCENTAGE
48
40
32
24
16
8
TOTAL MALE FEMALE
0
2007 2009 2011 2013 2015 2017
Figure 11.1 Percentage of high school students who ever had sex from 2007–2017.
Source: Youth Risk Behavior Survey 2007–2017, CDC.
Other research points to the average age of sexarche or first intercourse as

sixteen-and-a-half-years old with the suggestion that American teens are de-
laying the age of first intercourse (Francoeur and Noonan, 2004: 1188). Black
and Hispanic adolescents are significantly more likely to have had intercourse
than whites (Life’s First Great Crossroad, 2000: 16). In the Youth Risk Behav-
ior Survey in 2017, 45.8 percent of black high school students, 41.1 percent of
Hispanic students and 38.6 percent of white students reported having ever had
sex (CDC, 2017: 10). (See the following discussion of statistics on ethnicity
and sex/reproduction/contraception.) Some research has found that 11 percent
of males and females aged fifteen to nineteen years old had engaged in anal
sex with someone of the opposite sex; and 3 percent of males aged fifteen to
nineteen years old had had anal sex with a male (“Healthy Youth Sexual Risk
Behaviors 2006,” 2006; Mosher, Chandra, and Jones, 2003).
The National Youth Risk Behavior Survey 2007–2017 (“Data Summary and
Trends Report”) provides additional patterns for ninth through twelfth grade
students in private and public schools. This survey is conducted every two years
and augments the trends noted. The National Youth Risk Behavior Survey
2007–2017 includes evidence of changes in the following behaviors: decrease
in ever had sexual intercourse; decrease in those who have had four or more
partners; decrease in those sexually active three months before the survey; a de-
crease in condom use; and an increase in number of women using effective birth
control (birth control pills, an IUD or implant, a shot, a patch, or a birth control
ring). Alcohol or drug use before sexual intercourse increased from 1991 to 2001
and decreased slightly from 2001 to 2005. AIDS/HIV education increased from
1991 to 1997, but decreased from 1997 to 2005, suggesting an alarming trend.
The CDC’s National Survey of Family Growth tracked specific trends in types
of birth control used by adolescents from 2002 to 2015 (Figure 11.2).
Countervailing trends for adolescents to make pledges and promises for chas-
tity until marriage are occurring through religious organizations that emphasize
abstinence-only sexuality education. These efforts gained funding under the
Bush Administration, despite cautions by national and internationally recog-
nized bodies of sex educators including the American Association of Sexuality
Educators, Counselors and Therapists; Sexuality Information and Education
Council of the United States, and The International Planned Parenthood
Federation. How the George W. Bush administration’s policy of support for absti-
nence-only sex education will impact adolescent sexuality over time remains to
be determined. However, comparative statistics from other industrialized na-
tions can provide evidence of the influence of trends in sex education (see dis-
cussion). Former President Barack Obama shifted long-standing federal funding
for abstinence-only sex education to more comprehensive risk reduction educa-
tion through the Affordable Care Act and Teen Pregnancy Prevention (TPP)
program, which provides funding for organizations aimed at reducing teen preg-
nancy through risk reduction strategies (HHS.gov, 2010). Most recently, in 2018
President Trump announced that federal funding from TTP would be diverted
back to organizations that promote abstinence-only sex education.
Reiss’s “autonomy theory” (1967) has relevance for understanding histori-
cal and cultural patterns and changes in adolescent sexual expression. Auton-
omy theory argues that sexual permissiveness will increase in cultural contexts
in which adolescents have courtship and dating autonomy. Where systems
of control such as parents, religious institutions, and schools inhibit the au-
tonomy and independence of adolescents, premarital sexual permissiveness
will be reduced. The trend for increasing autonomy has been occurring in the
United States and other industrialized nations (Francoeur and Noonan, 2004;
Reiss, 1967).
95% CI 2002 2006-2010 2011-2015
94
Condom 96
97
55
Withdrawal 57
60
61
Pill 56
56
8
Emergency 14
Contraception 123
21
Depo-Provera 20
17
11
Fertility awareness 15
12
2
Patch 2
10
2
5
Ring
5
3
Intrauterine device
3
3
Implant 1
3
0 10 20 30 40 50 60 70 80 90 100
Percent
1
The Percentage of female teenagers who ever used emergency contraception increased significantly from 2002 to
2011-2015 (0<0.06).
2
The percentage of female teenagers who ever used the patch increased significantly from 2002 to 2005-2010 and
decreased significantly from 2006−2010 to 2011−2015 (ρ<0.05).
3
The percentage of female teenagers who ever used the implant inceased significantly from 2006-2010 to 2011-2015 (ρ<0.05).
NOTES: CI is confidence interval Neither the contraception ring nor the implant were available in 2002. The number of
teenagers who had ever used the intrauterine device in 2002 was too small to be statistically reliable.
Figure 11.2 Methods of contraception ever used among females aged 15–19 who had
ever had sexual intercourse.
Source: NCHS, National Survey of Family Growth, 2002, 2006–2010, 2011–2015.
Trends in the Prevalence of Sexual Behaviors and HIV Testing
National YRBS: 1991—2017
The national Youth Risk Behavior Survey (YRBS) monitors health behaviors that contribute to the leading
causes of death, disability, and social problems among youth and adults in the United States. The national
YRBS is conducted every two years during the spring semester and provides data representative of 9th
through 12th grade students in public and private schools throughout the United States.
Trend from Change from

Percentages
1991–20171 2015–20172
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017
Ever had sexual intercourse
54.1 53.0 53.1 48.4 49.9 45.6 46.7 46.8 47.8 46.0 47.4 46.8 41.2 39.5 Decreased 1991—2017 No change
Had sexual intercourse before age 13 years

Had sexual intercourse with four or more persons
(during their life)
Currently sexually active
(had sexual intercourse with at least one person during the 3 months before the survey)
Decreased 1991—2017
Used a condom
(during last sexual intercourse, among students who were currently sexually active)
Increased 1991—2017
46.2 52.8 54.4 56.8 58.0 57.9 63.0 62.8 61.5 61.1 60.2 59.1 56.9 53.8 Increased 1991—2005 No change
Used an IUD or implant
(before last sexual intercourse to prevent pregnancy, among students who were currently sexually active)
—3 — — — — — — — — — — 1.6 3.3 4.1 Increased 2013—2017 No change
Figure 11.3 Trends in the prevalence of sexual behaviors and HIV testing, CDC.
Trend from Change from
Percentages
1991–2017 1 2015–20172
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017
Used birth control pills
(before last sexual intercourse to prevent pregnancy, among students who were currently sexually active)
Did not use any method to prevent pregnancy
(during last sexual intercourse, among students who were currently sexually active)
No change 2007—2017
Drank alcohol or used drugs
(before last sexual intercourse, among students who were currently sexually active)
21.6 21.3 24.8 24.7 24.8 25.6 25.4 23.3 22.5 21.6 22.1 22.4 20.6 18.8 Increased 1991—1999 No change
Ever been tested for HIV
(not counting tests done if they donated blood)
—3 — — — — — — 11.9 12.9 12.7 12.9 12.9 10.2 9.3 No change 2005—2013 No change
1 Based on linear and quadratic trend analyses using logistic regression models controlling for sex, race/ethnicity, and grade, p < 0.05. Significant linear trends (if
present) across all available years are described first followed by linear changes in each segment of significant quadratic trends (if present).
2 Based on t-test analysis, p < 0.05.
3
Not available.
Puberty and Adolescence
Figure 11.3 (Continued).

Disclaimer: Reference to specific commercial products, manufacturers, companies, or trademarks does not constitute its endorsement or
263
recommendation by the U.S. Government, Department of Health and Human Services, or Centers for Disease Control and Prevention.
The evidence suggests that comprehensive sex education (which includes
AIDS education, discussion of various STI/HIV, and pregnancy prevention
options in addition to abstinence) delays initiation of sex and increases con-
traceptive use in youth (Haberland and Rogow, 2015: 19; Kirby, 2008: 24;
Starkman and Rajani, 2002: 317). In fact, abstinence-only sexual education is
positively correlated with teen pregnancy even after controlling for confound-
ing factors such as income, education, and ethnic diversity (Stanger-Hall and
Hall, 2011: 6). According to data from the National Survey of Adolescent Males
(NSAM), between 1988 and 1995, the rate of condom use at last intercourse
among fifteen- to nineteen-year-old males increased from 56 percent to 69 per-
cent (Murphy and Boggess, 1998), although data from the Centers for Disease
Control and Prevention indicates that in 2005, 34 percent of currently sexually
active high school students did not use a condom during last sexual intercourse
(“Youth Risk Behavior Surveillance-United States, 2005”), [2006, see Figure 11.3].
It is possible to become pregnant during first intercourse and it is also pos-
sible to contract HIV as well. We cannot assume that US adolescents are
using contraceptives regularly. The rate of contraceptive use with first sex
has increased substantially among adolescents. For females (ages fifteen to
nineteen) in 2002, 75 percent used some form of contraception at first inter-
course, while 82 percent of males (ages fifteen to nineteen) did so. Despite this
90
80
70
PERCENTAGE
60
61.5 61.1 60.2 59.1
56.9
50 53.8
40
30
20
10
2007 2009 2011 2013 2015 2017
Figure 11.4 Percentage of high school students who used a condom the last time they
had sex.
Source: Youth Risk Behavior Survey 2017, CDC.
Disclaimer: Reference to specific commercial products, manufacturers, companies, or trademarks
does not constitute its endorsement or recommendation by the U.S. Government, Department
of Health and Human Services, or Centers for Disease Control and Prevention.
positive trend, teens are inconsistent in contraceptive use. For example, only
28 percent of females and 47 percent of males reported use of a condom every
time they had penile-vaginal sex in the previous twelve months (Franzetta
et al., 2006). Condom use has decreased significantly in high school students
since 2007; from 2015 to 2017, the percentage of teens who used a condom
the last time they had sex decreased from 56.9 percent to 53.8 percent (see
Figure 11.4).
Using contraception is difficult for adolescents since it is loaded with sym-
bolic meaning about oneself as a sexual being. By using contraception ado-
lescents must acknowledge that they are engaging in preplanned sex. This
may lead to conflicting feelings regarding values and sense of self as a “moral”
being. Concerns about privacy and parent approval of sexual behaviors can
deter adolescents from using contraceptives as well, particularly in families
and communities with strong cultural values related to sexuality (Caal et al.,
2013: 620; Gilliam et al., 2009: 100) With adolescence in industrialized soci-
ety comes a number of questions for the individual concerning sexuality and
contraception.
Adolescent Fertility and Sterility

The decision to engage in sex is not without risks. AIDS and other STDs
are endemic in this culture as are the consequences of an unwanted preg-
nancy. Teen pregnancy is a particular problem in the United States. Why is
the United States’ adolescent pregnancy rate higher than in other industrial-
ized countries? What factors influence teen pregnancy from a socio-cultural
perspective? One possible contributing factor is a phenomenon known as ad-
olescent sterility. This is presented in greater depth in our discussion of birth
control in Chapter 8. Adolescent sterility or subfertility refers to a period be-
tween the age of menarche and reproductive maturity, which occurs at about
twenty-three years old. Despite the onset of puberty, intercourse is less likely
to result in pregnancy than in a reproductively mature woman (Ford and
Beach, 1951: 172–173). In a number of societies, adolescent females are per-
mitted premarital sex, yet pregnancies are unlikely to result (Ford and Beach,
1951). Adolescent sterility occurs in societies that Ford and Beach (1951: 190)
list as permissive (i.e., there are no sexual restrictions on adolescent sexual
activity short of incest regulations). The list of permissive societies is too long
to reproduce here, but examples include the Ainu, Aymara, Trobriand Island-
ers, and Yapese among numerous others. Ford and Beach (1951) list forty-nine
societies, although adolescent sterility does not necessarily correlate with this
entire list.
Adolescent sterility allows teenagers and youths to experience their sex-
uality as well as learn and grow as individuals. It provides for an extended
period of practice and discovery about oneself as a sexual being without
the burden and the additional concern and responsibility of parenthood.
Sexual experimentation in these societies allows for a far easier transition to
marital sex than in societies which prohibit exploration during adolescence,
and then expect that the couple will be able to reverse their attitudes about
sex after marriage (Ford and Beach, 1951: 195). Adolescent subfertility in
combination with permissive cultural attitudes also provides for an import-
ant period of learning without the status changes that accompany child-
birth. In most societies, childbirth provides men and women special status;
sometimes it may confer adulthood while in others adulthood may occur
prior to parenthood. Regardless, having a child is viewed as an important
status marker.
As we suggest in Chapter 8, adolescent sterility does not seem operative
in US populations. Based on the “critical fat hypothesis” (Frisch, 1978), it is
believed that ovulation occurs only when certain relative levels of body fat
have been reached. This is directly related to the requirements for successful
reproduction and lactation. Lancaster (1985: 18) attributes the loss of adoles-
cent sterility among teenage girls in contemporary societies to: “[s]edentism
combined with high levels of caloric intake [that] lead to early deposition of
body fat in young girls…”; this “ ‘fools’ the body into early biological mat-
uration long before cognitive and social maturity are reached” (Lancaster,
1985: 18).
Without adolescent sterility as a damper on fertility in combination with
adolescent sexuality without contraception, the result is a very high adolescent
pregnancy rate in the United States. In the 1980s, for every 1,000 females, 110
aged fifteen through nineteen became pregnant (Henshaw et al., 1989). Teen
pregnancy rates peaked in 1990, but since then, US teenagers have shown a
decrease in these rates by 22 percent (see Figure 11.5). More recent data from
2017 show an average of 18.8 births for every 1,000 adolescent females ages
fifteen to nineteen with a decreased birth rate of 6 percent from 2016 to 2017
(HHS.gov, 2017).
This differentially impacts adolescent African American females where
adolescent pregnancy is twice as high as for Caucasian females in this
age group. If we compare Caucasian female pregnancy rates with those
of African American teens, the former shows a rate of 71.4 per 1,000
girls while African American women show a rate of 153.3 per 1,000 (“US
Teenage Pregnancy Statistics,” 2004). See discussion regarding absti-
nence-only sex education and comprehensive sex education in industrialized
nations.
Interestingly, in comparison with thirty-seven other countries, the US preg-
nancy rate is “higher than that of almost any other industrialized country.
While US adolescents are no more sexually active than young people in other
industrialized countries, they are much more likely to become pregnant” (Byer
and Shainberg, 1991: 386; also Darroch et al., 2001). While there appears to be
no difference between the United States and Europe in the age that teens ini-
tiate sex, European teens are more likely to use effective birth control (Santelli
and Melnikas, 2010: 376).
120
116.2
100
Birth rates per 1,000 females ages 15-19
100.3
Hispanic
80
Black
60
59.9
Total
40
42.5
28.9
White
27.6
20
18.8
13.4
0
90
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
20
20
20
20
20
20
20
20
20
19
19
19
19
19
19
19
19
19
19
20
20
20
20
20
20
20
20
20
Year
Figure 11.5 Birth rates per 1,000 females ages 15–19, by race and Hispanic origin of
mother, 1990–2017.
Source: “Trends in Teen Pregnancy and Childbearing” HHS.gov.
Unfortunately, the statistics for the United States, and the other countries
for that matter, do not distinguish differences among ethnic groups and other
minorities. Nevertheless, these differences between the United States and
other industrialized nations have been largely attributed to the absence of:
• national comprehensive sex education programming;

• readily available birth control; and
• a sex-positive attitude in this culture in contrast to other industrialized
societies.
If we in the United States are to reduce pregnancy and STI rates effectively, we
must desensitize the issue of condom use and remove taboos associated with this
method (Sinding, 2005). It is also important that we not only provide condoms
but make available information on how to use condoms correctly in a culturally
sensitive manner to enhance their effectiveness (Sinding, 2005). In summary,
lessons from industrialized countries with low levels of teenage pregnancy/birth
and STIs correlate social acceptance of adolescent sexual relations with com-
prehensive sexuality education that emphasizes the avoidance of STIs/HIV and
pregnancy prevention, and provides easy access to contraceptive and reproduc-
tive health sources (“Teenagers’ Sexual and Reproductive Health,” 2004).
What is the price of adolescent pregnancy and childbirth?
• Teen mothers are more likely to drop out of school than their peers and
are significantly less likely to earn a high school degree or to earn a college
degree.
• Teen motherhood costs the United States approximately $16,000 per teen
birth (NCSL, “Teen Pregnancy Prevention” 2019).
• The children of teen mothers are often more inclined to have health prob-
lems which are a result of birth weight and premature births. Low birth
weights lead to problems in childhood development and extended health
risks (Weiss, 2000, 2006).
Growing evidence suggests that teen mothers’ prior backgrounds, with the ma-
jority of them being non-white and economically disadvantaged, plays a larger
role in negative consequences than the teen pregnancy itself (Patel and Sen,
2012: 1070; SmithBattle, 2006: 131), although more long-term research needs
to be done. Other problems prevail among teenage mothers. Adding to their
economic vulnerability is an increased likelihood of a repeat birth to teenaged
mothers; approximately one in five give birth each year (CDC “Vital Signs”,
2013). Children of teenaged mothers are at a higher risk of having educational
difficulties and disabilities that are related to their mother’s socio-economic
positioning (Weiss, 2006; “Young Mothers Disadvantage, Not Their Age It-
self,” 2001).
Sex Education in the United States

Directly related to the problem of teenage pregnancy is the issue of sex ed-
ucation in the United States. Sex education in the United States can be
contrasted with traditional non-technologically complex societies. As we dis-
cussed previously, families whose sleeping quarters are shared provide an op-
portunity for children to become aware of the sexual activities of their parents
and/or siblings. Sex in these situations is undertaken with discretion, and we
know of no culture in which children and youths are allowed to watch openly.
For example, among the Mangaians, a sex-positive Polynesian culture in which
premarital sex is the norm, parents do not discuss sex with their young chil-
dren. But because Mangaians live in one-room houses, the opportunity for
discrete observation does occur. However, the specifics and details of sex and
reproduction are learned outside the home, not unlike in the United States
(Marshall, 1971: 109).
Without rites of passage to help them make the transition to adult status
and also to provide avenues for learning about sexuality, where do industri-
alized adolescents learn about sexuality? Research suggests that it isn’t from
parents, but rather from peers and online media sources (Fox and Ralston,
2016: 636; Harris, 2011: 236). This is not to suggest that parents have no in-
fluence on their children’s sexual behavior. In fact, during the childhood and
the “tween years” (ages nine to thirteen), parents are the most important influ-
ence on children’s lives regarding their values, attitudes, and beliefs. However,
a national survey by the Kaiser Foundation of fifteen- to seventeen-year-olds
regarding parent-teen communication found:
• Many teens wait until after they have had sex to talk to their parents
about sex (i.e., if they ever do). One in four teen girls and nearly one in
two teen boys who have had sexual intercourse say their parents don’t
know about it.
• Among parents in the know, many are finding out about their teens’ sex
lives later than they might like to, or at least too late to have an influ-
ence on the choices their children make, or to encourage them to protect
themselves.
• Of all the teens surveyed—including both those who have had sex as well
as those who have not—half have never had a conversation with a parent
about how to know when you are ready to have sex.
• Even fewer have talked with a parent about how to bring up topics like
birth control, condoms or sexually transmitted disease (STD) testing with
someone they are dating.
• Most teens aren’t talking about their sexual health with a doctor either.
Less than a third report having talked with a health care provider about
HIV/AIDS, other STDs, or condoms (“Sex Smarts: A Public Information
Partnership,” 2002).
Communication between parents and children is an essential ingredient in ad-

olescent sexual behavior; open communication with parents has been shown
to influence the timing of first intercourse and whether protection against STI
and pregnancy occurs (“Sex Smarts: A Public Information Partnership,” 2002).
A study of 1,000 parents of thirteen- to seventeen-year-olds found that there
are gender, ethnic, and socio-economic variables related to teen-parent com-
munication (Swain, Ackerman, and Ackerman, 2006: 753.e9):
• Low income, minority parents reported more discussion with their teens
about the negative consequences of sex and where to obtain birth control
than high income, white parents.
• Politically conservative, religious parents reported more discussion with
their teens about the negative consequences of sex than their liberal and
non-religious counterparts.
• In general, non-religious parents reported more discussion about where to
obtain birth control than religious parents.
• Parents were less likely to talk with males, younger teens, and teens not
believed to be romantically involved.
The CDC also reports that female teens are more likely to talk to their parents
about sex: two out of three teenage girls talked to their parents about saying
no to sex compared to only two our of five males who did the same (Martinez,
Abma, and Copen, 2010: 1). Two thirds of sons in another study reported that
they had not talked with their parents about how to use a condom (Beckett
et al., 2009: 39). Forty percent of girls from the same study had not talked to
their parents before starting birth control (Beckett et al., 2009: 40) Salience
of gender in parent and teen discussions (see last bulleted point) has been
recorded by other researchers as well. Wilson and Koo (2010: 7) found that
daughters are more likely to talk to their mothers about sex but prefer to talk to
fathers about topics relating to dating and relationships. Mothers of daughters
are also more likely to recommend that they wait to have sex more than moth-
ers of sons. Both daughters and sons are more likely to talk to their mother
about sex over their father.
The mass media should not be underestimated as a source of sex education
(Kunkel et al., 2003, 2005). In fact, media, specifically television viewing, takes
precedence over the peer group according to some researchers (Kunkel et al.,
2003, 2005). In fact, Brown, Halpern, and L’Engle (2005) refer to the media
as the “sexual super peer.” Research indicates that children and adolescents
watch on the average three hours of television a day. Television can have both
a positive as well as negative outcome on young people’s sexual decision mak-
ing, including use of safer sex and pregnancy prevention strategies. Donner-
stein and Smith (2001) and Gunter (2002) regard television as an important
vehicle for sexual socialization of adolescents influencing knowledge, values,
beliefs, attitudes and behavior (in Kunkel et al., 2005). Although television
programming, which may offer sexuality education information (e.g., STI/HIV
information, safer sex and pregnancy prevention has increased since 1998), it
has subsequently leveled off since 2002.
The Internet is a substantial resource for sexual education. Adolescents
commonly search for topics related to HIV/AIDs, pregnancy, contraception,
sexual anatomy and sexual orientation. With 73 percent of the teenage pop-
ulation using social media, web-based interventions could have a significant
impact on adolescent sexual health (Simon and Daneback, 2013: 308). Gold
et al. (2011: 5) identified the amount of social networking sites (SNS) used to
educate people about sexual health and involve health promotion. The study
found that out of 178 online health promotion activities, 58 percent used at
least one SNS. Future research should work to identify how much SNS are
utilized by adolescents to learn about sexual health.
Other significant sources of information on sexuality and influences on
adolescent sexuality besides parents and the mass media include schools,
political policy, and religious institutions (Halpern et al., 2000). Virginity
pledges are abundant in church programming, although not all churches sup-
port abstinence-only approaches. For example, a survey of African American
churches found church leaders were open to including sexuality as a topic
for their health education programs, including information on contraceptive
education (Coyne-Beasley and Schoenbach, 2000). The “virginity pledge”
approach was begun by the Southern Baptist Church with their “True Love
Waits” program. Virginity pledges burgeoned in the mid-1990s especially
among evangelical Christian organizations. However, research has found that
teens making a private pledge to wait until they are more mature to have sex
is more effective in reducing the likelihood that they will engage in sexual in-
tercourse and oral sex. This is contrasted with those who made formal pledges
such as a virginity pledge, which had no effect on teens’ sexual behavior (Ber-
samin et al., 2005: 428). There is no significant difference in age of first sex or
sexual activity between those that take virginity pledges and those that do not
(Rosenbaum, 2009: 7). Virginity pledgers are less likely to use contraceptives
than non-pledgers. This is in part due to a mistrust of contraceptives in pop-
ulations that practice abstinence only, and through virginity pledging (Paik
Sanchagrin, and Heimer, 2016: 4).
In contrast to this research, which showed no effect on teenage sex, Han-
nah Brückner of Yale University and Peter Bearman of Columbia University
conducted a study of virginity pledging teens and reported virginity-pledging
teens were actually more likely to engage in riskier sexual behavior; they were
less likely to use condoms, and more likely to engage in oral and anal sex. In
addition, intercourse was only delayed (but not prevented) by twelve to eigh-
teen months among the virginity pledgers and they were less likely to know
their STI status (Brückner and Bearman, 2005: 271–278; Wind, 2005).
The public and private school systems in the United States that offer sex
education curriculums are also an important institution in teen sexuality edu-
cation. Nationwide, schools are not uniform in terms of content and coverage.
Socio-economic variables influence teen sexual expression and can impact the
influence of variables such as religion, the schools, and the mass media. Ac-
cording to the Centers for Disease Control and Prevention, students attending
schools in rural or high poverty regions are more likely to engage in adolescent
risky sexual behavior and unprotected sex (Underwood, 2019: 38). Further-
more, students in sexual minorities (lesbian, gay and bisexual students) are less
likely to use contraceptives such as birth control or condoms. Data regarding
the use of other protective barriers, such as dental dams, was not collected
(CDC, 2017: 60). Inequalities in sexual behavior are further stratified in this
group by socio-economic status (SES): young men who have sex with men that
are foreign-born or have low SES engage in riskier sexual behavior (Halkitis
and Figueroa, 2013: 187).
Concerns over sex education gained prominence in the 1960s as a result of
SIECUS (The Sex Information and Education Council of the United States)
and AASECT (the American Association of Sexuality Educators, Counselors
and Therapists). Research indicates that the question of sex education is not “if”
such programs should occur but rather “what kind of approach.” Surveys indi-
cate that that the majority of Americans favor more comprehensive sexuality
education; that is, education that includes information on a variety of options,
over abstinence-only education (“Facts in Brief: Sexuality Education: Sex and
Pregnancy among Teenagers,” 2002). Keep in mind that comprehensive sexu-
ality education programs in schools are still fairly rare. Currently, 24 states and
the District of Columbia require sex education. In regards to content of sex ed-
ucation, 18 states mandate that contraception must be included in curriculum,
and 37 states require that abstinence is included in curriculum (Guttmacher
Institute, 2016).
Sex education programs vary a great deal in their success rates. Though
a number of stances may be taken, we have an excellent example of what
doesn’t work. This has historical precedence: the “Reaganesque” “Just Say No”
approach of the 1980s. This slogan was the result of a 1981 effort to reduce
teenage pregnacies without advocating birth control through the Adolescent
Family Life Act (ALFA), a congressional act that funded programs promoting
premarital abstinence. One study even found that “participants [in one ALFA
project] engaged in more sexual activity than controls” (Troiano, 1990: 101).
While funding for AOUM programs through the AFLA Act ceased in 2010,
Congress created the Sexual Risk Avoidance Education program to continue
support for abstinence-focused sex education (Santelli et al., 2017: 275). This
program exists in conjunction with the Teen Pregnancy Prevention (TPP)
program that was created by President Barack Obama in 2010. This program
sought to shift funding from AOUM policies towards more comprehensive,
risk reduction programs to prevent teen pregnancy. These programs include
the promotion of contraceptives in adolescent populations and culturally sen-
sitive sex education (HHS, 2017). Despite the TPP program, congress increased
federal funding for AOUM by $85 million dollars in 2016 (Hall et al., 2016: 1).
Since scare tactics have proven ineffectual, sex education curriculums
whose goals are to reduce adolescent pregnancy (and STI/HIV) through the
use of contraception can be very successful. Such programs must take a mul-
tidimensional and comprehensive approach (Troiano, 1990: 101). By that, we
mean that not only should the mechanics of reproduction be addressed, but
the psychological and social aspects as well, including lesbian, gay, bisexual,
and transgender issues. Concern over the threat of HIV/AIDS has recently
given a new impetus to sex education. Other societal trends are also reflected
in new approaches to sex education development. For example, sexuality is in
a historical niche where it is now regarded as an important and very natural
component of one’s life. This view is also related to trends in which sex and
procreation were separated resulting in a greater emphasis on sex for pleasure.
These patterns are in their incipient stages and are just beginning to be felt in
sex education which is still suffering from conservative paradigms of fear and
abstinence only.
The evidence in regard to abstinence models is intriguing. Apparently, sex
education programs do not impact the likelihood of sexual activity one way
or another, but rather may actually increase the likelihood of contraception
and hence affect pregnancy and STI transmission including HIV infection
(Kirby, 1984; in Kelly, 1990; Kirby, 2001: 337–340). This is expressed in the
contrast between European sex education programs and those in the United
States. European programs take for granted that adolescents are having sex
and their approach consequently focuses on the issues of how to combat STIs/
HIV and pregnancy (Francoeur, 1991a: 125; Boonstra, 2002): “Americans are
mainly concerned with keeping teenagers from being sexually active and en-
joying it” (Francoeur, 1991a: 125); and US adults are less accepting than their
European counterparts about teens having sex. European adults and their sex-
uality education programs carry a message that sex is a natural part of commit-
ted relationships and that teenagers have a responsibility to practice safer sex
strategies and prevention of pregnancy (Boonstra, 2002).
Extensive yet ineffective programming is abundant in the United States.
This has arisen from the explicit assumption that teens do not posses enough
information on sexuality in general and its consequences (Francoeur and
Noonan, 2004: 1192). The truth, however, is that teenagers are receiving
plenty of sexual information from peers and the media, yet our prevalent
abstinence-only approaches are severely ineffective in their assumption that
teens will discontinue sex as a recreational activity (Koch, 2004: 1174–1175).
Adolescent birth rates declined from 2007 to 2014 despite a paradoxical de-
crease in sex education from 2006 to 2013 (Lindberg et al., 2016; Hall et al.,
2016). In 2017, condom use among high school students actually decreased
from 62 percent in 2007 to 54 percent (CDC, 2017: 9). Additionally, the use
of contraceptives, particularly the “pill,” by sexually active teenage women is
lower in the United States than in other industrialized countries. This con-
tributes to the high pregnancy rates in the United States as compared with
other industrialized countries (Guttmacher Institute, 2017: 2); on a global
scale, the United States has a significantly greater use of contraceptives than
industrialized countries (United Nations, 2019 1) Until very recently, all fifty
states had taken advantage of federally sanctioned abstinence-only sex educa-
tion funding available for use in high schools. Several states, however, includ-
ing Maine, Pennsylvania, and California, turned down this federal subsidy for
sex education specifically because it did not include a comprehensive approach
(Kehrl, 2005).
Comparison and Contrast: Preparation for and Transition

to Adulthood
Adolescence is a culturally constituted phase associated with puberty. As we
have discussed, whether a culture even acknowledges a period of adolescence
differs, as does the length of time allocated to such a stage. Therefore, adult-
hood and the age at which we are perceived to reach it also differs consid-
erably. Despite the variability of how and when children reach adulthood,
cultures provide mechanisms for the change of status. As we have seen, this
occurs through rites of passage.
As we introduced earlier, Mead’s study of Samoan girls’ adolescence chal-
lenged our own industrialized conceptions of adolescence as a period of strife
due to the pubescent surge of hormones. Mead’s study refuted this view in a
controversial analysis that argued that Samoan girls experienced a harmonious
adolescence. Mead was as interested in US adolescence as she was in Samoan
adolescence and has provided some clues about the industrialized adolescent
experience at the time. Some of her ideas still ring true since the publication of
her book, Coming of Age in Samoa, in 1928, although parts of her conclusions
are dated. For example, her frustration hypothesis with its obvious Freudian
dimension is regarded as a questionable explanation. Mead’s interpretation of
why adolescence was such a torturous time for US youths rested on the idea
that urges for sex were frustrated and suppressed by norms against teenage sex.
This thesis ignored other dimensions of adolescence as a period of growth. In
the United States, these norms were associated with the age of marriage which
at the time was ideally delayed until after graduation from high school. Mead
felt that teenage sexual norms that allowed making out and petting just flamed
a libidinal inferno that must ultimately be repressed. Teens expressed their
frustration with this through rebellion and revolt (Davis, n.d.: 3). In Mead’s
view, US culture emerged as a repressive one and Samoan culture was regarded
as permissive because these sexual urges in teenagers were not frustrated.
Like Mead, Spock regarded as the US expert on childrearing, has also ac-
cepted rebelliousness as a given for adolescents. In this regard he stated: “It isn’t
often realized that the rebelliousness of adolescents is mainly an expression of
rebelliousness with parents, particularly the rivalry of son with father and girls
with mother…” (with Rothenberg, 1985: 503). In contrast to Mead, Spock and
Needlman (2004) recognized rebelliousness as a powerful and positive force
leading to the establishment of autonomy in the individual and ultimately to
creative change in society. While the question of US adolescent strife is inter-
esting, there is a danger in perspectives such as Mead’s and Spock’s when ap-
plied to a complex society such as ours. Dona Davis’ (n.d.: 4) comment relates
equally as well to Spock, although it addresses Margaret Mead:
This…comparison of types…not only stereotyped sexual behaviors in

non-Western societies, it stereotyped adolescent sexual behavior in our
society. Researchers ignored the social complexities of sexual styles among
adolescents as well as the many and various ways in which young people
negotiate the rules of their culture to achieve sexual satisfaction.
(Davis, n.d.: 4)
Although there is a widespread belief that adolescence is a period of turmoil

for US teens, we must be careful not to overgeneralize. Bear in mind the im-
portance of ethnicity and socio-economic status as factors affecting how ad-
olescence is experienced and expressed. This is not to say that we cannot
describe some of the patterns among US adolescents, but that we must re-
member these trends usually represent the white middle class, and by so doing
gloss over the variety of expressions of US adolescence among different ethnic
groups and classes.
Let us contrast what we have learned about rites of passage (discussed earlier
in this chapter) with the experience of the US teenager. Again, we are not
referring to the various indigenous and ethnic peoples in the United States
that may have very rich rites of passage. For example, many Native American
peoples maintain their traditional rites of passage for young females and males
including the vision quest, and the Jewish bar/bat mitzvahs also provide criti-
cal recognition of life-passage changes as do many other immigrant and ethnic
groups. As the industrialized child undergoes puberty with its accompanying
physical signs, are there any rituals or rites of passage that publicly recognize
these changes on a cultural level? Although individual parents may celebrate
their daughter’s first menstruation when that occurs, very often it is treated
with secrecy and embarrassment. With the growth of male body hair and
deepening of the voice, a father may acknowledge this with “You’re a man
now, son!” But what does that mean? The meaning is not spelled out, neither
are the markers of adulthood evident. Where are the ritual referents to know
when adolescence is over and adulthood starts? How does an adolescent know
when this is going to happen?
In the United States, generally the transition to adulthood is a diffused one
unmarked ritually. We live in a ritually poor society. Though the symbolic
aspects of adulthood are few, there are several societal markers that give an
individual the legal status of adult as opposed to that of minor. This is known
as reaching the age of majority and includes issues such as: the age at which
one is considered a consenting adult, the age at which an individual may be
married, and the age one may be tried in court as an adult. These vary state
by state. Other events that may contribute to adult status include economic
independence, marriage, and the birth of a child. But none is sufficient in and
of itself as a clearly defined event that identifies the individual as an adult.
In short, adulthood, for many US people occurs in an unintegrated way, in
contrast to US ethnic groups and nonindustrialized societies in which distinct
symbolic referents for adulthood are expressed ritually or ceremonially. The in-
dustrialized adolescent finds herself/himself no longer a child, but certainly not
an adult. They are betwixt and between youth and adulthood in a society that
provides very little in the way of well-defined status markers. In fact, they often
receive conflicting messages from society about their transitioning through the
stages from childhood to adulthood.
Initiation ceremonies are well known for their ritual ordeals, yet the nov-
ices know that at the end of these tests they will be unequivocally declared
adults. In contrast, US adolescents generally have no tests or tasks that once
accomplished will identify them unequivocally as women and men. Without
rituals of transition to guide the adolescent on a journey into adulthood, social
adaptation and transition to adulthood may breed areas of conflict and tension
(Shapiro, 1979: 283). One of these is in the area of sexuality. In fact, Miller and
Simon (1980: 153) have described adolescent sexuality as “behavior in search
of meaning.”
The US teenager is kept in a liminal status of no longer a child but not yet
an adult despite their biological maturity. In our society, adulthood is associ-
ated with sexual rights and until that time teenagers do not “own” their own
bodies—they do not have the freedom to experience their sexuality until they
are adults. This is supported as well by the legal system. Thus, US teenagers
may be fully functioning sexual beings, but they are not regarded as having
rights to that sexuality. In this regard they are still children. Their sexual de-
sires are not regarded as legitimate as adult ones.
This situation stems from a variety of sources, including an industrialized
sex-negative or sex-ambiguous worldview, a dogma that confounds sex with
romantic love, definitions of adulthood, and conflicting attitudes about con-
traception and abortion. Though adolescent sexuality is a complex issue, one
dominant perspective regards teenagers as too immature psychologically to
handle the sexual experience, although we have seen this is not the case in
many societies that are not sexually restrictive or in European industrialized
societies. We must, however, pay attention to the cultural context of the ad-
olescent experience in the United States. The industrialized view of sex is
that it is not to be taken casually (Clement, 1990: 58; Herdt, 2004). There is,
however a double standard that allows males more leeway in this regard than
females (Reiss, 1967). This standard is one which stems from the equation of
love and marriage, and expands to also include premarital couples. As a result
sex is problematic for many US adolescents.
We must also remember that the world is getting smaller through global-
ization, migration, emigration, and the Internet. It is all the more important
to emphasize the cultural factors in the construction of adolescence including
ethnicity, class, and other social and economic variables as these intersect
with the gender and sexual system of young people approaching adulthood.
Teenage pregnancy and the concomitant reduction in life changes, STIs and
AIDS are all-important issues in adolescent sexuality. US ambivalence about
teenage sexuality, in contrast with other industrialized nations, leaves US
youths undereducated regarding sexuality and hence unprepared for making
informed decisions about the many challenges to their health and life chances
as we have discussed. Early pregnancy and childbirth, inequities in power for
adolescent girls in making decisions affecting their sexual health, STIs, AIDS,
and the exacerbation of these problems because of poverty are incredible chal-
lenges facing us today.
Summary
1 Puberty is a physiological phenomenon, while adolescence is a cultural
one that may or may not be coterminous with puberty.
2 Rites of passage were introduced as rituals that facilitate the transition
from childhood to adulthood.
3 Rites of passage have three phases and distinct functions in nonindustrial
societies.
4 Theories of rites of passage were addressed. Female ceremonies are more
common, but male ceremonies are more elaborate and severe.
5 Female genital cutting was discussed including prevalence, practices, and
controversial issues.

ash/oah/adolescent-development/reproductive-health-and-teen-pregnancy/teen-
pregnancy-and-childbearing/trends/index.html.
Darroch, Jacqueline, Jennifer J. Frost, Susheela Singh, and Study Team. 2001. “Teen-
age Sexual and Reproductive Behavior in Developed Countries: Can More Progress
Be Made?” Occasional Report Number 3. The Alan Guttmacher Institute, Novem-
ber 1–120. http://www.guttmacher.org. Last accessed 11/09/07.
Ashcraft, Amie M, and Pamela J Murray. “Talking to Parents about Adolescent Sex-
uality.” Pediatric Clinics of North America, U.S. National Library of Medicine, April
2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5517036/.
Stages, Part III
Adult Sexuality
Chapter Overview
1 Discusses the importance of culture in shaping beliefs and practices and
introduces erotocentricty.
2 Focuses on the ethnographic and cross-cultural record and human sexual
response, including Mangaian and Tantric perspectives.
3 Presents classic and contemporary industrialized theories of sexuality.
4 Outlines major topics in problems of desire and sexual response.
5 Emphasizes the importance of context and culture in understanding con-
cerns with sexuality, including industrialized approaches.
6 Examines nonindustrialized and indigenous emic perspectives regarding
issues in sexual functioning.
7 Explores the phenomenon of hookup culture and social media.
8 Discusses parenting styles.
Experiencing Sexuality and Human Sexual

Response (HSR)
How we experience and express our human sexuality is a physiological re-
sponse that occurs within the larger context of culture. Like other behaviors,
human sexuality varies cross-culturally and is influenced by:
• Our adaptation to the environment (how people survive).

• Social organization including family and kin group.
• The structure and complexity of the political and economic systems in-
cluding rank, class, and power.
• Sacred and religious systems.
• Gender stratification and the position of women in society.
• Gender ideologies and expectations, including status, roles, and gender
relations.
These are just some of the cultural influences shaping human sexuality.1
Anthropologists and others have recently turned their attention to scru-
tinizing even further the “variations in meanings and narratives between
280 Adult Sexuality
individuals, across cultures, moving research, education and policy closer to the
voices and experiences of local cultures and their moral worlds” (Herdt, 2004:
48). How humans experience their sexuality in terms of desire, arousal, and ex-
pression is a biological, psychological, and cultural phenomenon. The biology/
physiology of sexuality is encountered through the lens of culture which in-
forms our psycho-emotive worlds. According to Herdt (1999: 101), there is also
a great deal of individual variation among us in our sexual subjectivity (i.e.,
how we experience and express sexuality), including individual attributes like
personalities, histories, and sense of self. Each of us brings subjectivity into our
interpretation of our society’s sexual system, to include both internal meanings
as well as those derived from the wider social system. An interest in how indi-
vidual variation intersects with the cultural in understanding sexuality is part
of a broader revolution in anthropology that has challenged notions of homo-
geneity and stability (Herdt, 1999; Manderson, Bennett, and Sheldrake, 1999;
Suggs and Miracle, 1999). Culture must therefore be understood as dynamic,
containing elements of contradiction and negotiation as well as historicity and
must be inclusive of individuals and events (Bolin and Granskog, 2003).
By presenting human sexuality in its widest possible scope, incorporating
biological, psychological, and cultural perspectives, with attention to the sub-
jectivity and agency of individuals within their cultural matrix, our intent is to
avoid Euro-American erotocentricity—that is, using our own values in judging
the erotic lives and sexual cultures of other people.
The sexual values of the industrialized world are not the only standard
for sex, nor are these always the best or “right way.” Nonindustrialized
societies and indigenous cultures are not exotic, strange, bad, or wrong—
in short, “other.” Approaching sexuality through cultural relativism will
facilitate an appreciation of other cultures and lead us to a critical anal-
ysis of our own industrial worldviews. Industrial society did not create
sex, nor are its citizens the only ones with theories of human sexual re-
sponse. Ethnocentrism operates like blinders, shaping our view of what
is normal and abnormal and good and bad. Ethnocentrism prohibits us
from accepting variation for what it is, the expression of our biological,
psychological, and cultural diversity.
The Cross-Cultural Spectrum: Indigenous and

NonIndustrialized Sexuality
The ethnographic record is filled with sexual behaviors both familiar and for-
eign to the denizens of industrial society. Cross-cultural evidence highlights
not only the vast spectrum of sexuality, but its equally dramatic variation in
meaning, metaphor, and symbol. The social construction of sexuality (cul-
tural constructionism) (i.e., how societies produce and create sexual mean-
ings, behaviors and subjectivities) is not only important in fostering cultural
Adult Sexuality 281
awareness, but is crucial in formulating strategies to deal with global social
problems such as HIV/AIDS and other STIs, unplanned pregnancies, and wom-
en’s reproductive rights. Vance and Pollis assert that cultural constructionism:
[has] suggested that sexuality was not a biological given determined by

organs and acts but a profoundly social product in which bodily sensations
were linked to sexual acts, identities and meanings in ways that were fluid
and changeable over place and time.
(1990: 2)
The importance of culture in the patterning of sexuality has been the cor-
nerstone of anthropological research on this subject. (For anthropological re-
search emphasizing evolutionary and more biologically framed approaches to
sex see Chapter 3.) The now classic ethnographic studies that emphasized or
included data on sexual practices such as the work of Malinowski (1961 [1927]),
Benedict (1934), and Mead (1961 [1928]), among numerous others, provided
the fodder for the HRAF files and ethnology, furthering the comparative study
of cultures (discussed in Chapter 1). The HRAF allowed for cross-cultural
comparisons for hypothesis testing, identifying trends, patterns, and themes
in sexual behaviors. As noted earlier, Ford and Beach (1951) offered the first
and most provocative work on sexuality at the time, providing a compendium
of information on the details and specifics of sexual practices and beliefs. The
ethnographic and the comparative perspectives represent two approaches that
are still current in the cross-cultural study of sexuality. However, as definitions
of sexuality have changed over time, so has the discipline of anthropology and
the interests of anthropologists.2
Herdt (1999: 102–103) and others have commented on the changes that have
occurred in anthropological research since the early days of ethnography: “an-
thropologists from the 30s to the 70s, largely ignored erotics and sexuality, the
body, the emotions of the individual actor, and the passions pertaining to them”
(e.g., Lewin and Leap, 1996). Sexual excitement and orgasm were completely
unstudied until recently. Differences in meanings of social practices, such as
the difference between the genders and their experience of sexual relations,
were largely ignored in the paradigm (Vance, 1991). Even more fundamental is
the thesis that nonindustrialized communities differ substantially in sexual and
social desires; hence, different individuals within the same social strata or class
or age group might feel contrasting or even aberrant desires compared with their
peers or contemporaries in the society (Herdt and Stoller, 1990). Consequently,
it is not so curious that the cross-cultural study of sexuality advanced so little
until the recent work of a small number of heterosexual scholars, followed by
feminist and gay and lesbian scholars after the 1970s (Gagnon and Parker, 1995).
Until relatively recently the ethnographic research was far richer on the
subject of heterosexual erotic preferences rather than homoerotic and bisexual
behaviors with a few exceptions, such as the earlier work of Westermark (1956
[1906]), Stewart (1960), and Ford and Beach (1951), to name a few. Over the
282 Adult Sexuality
past thirty-five years this situation has been in the process of being remedied
through the work of anthropologists such as Gilbert Herdt, Walter Williams,
Evelyn Blackwood, Ester Newton, Kath Weston, and Richard Parker, among
numerous others (Manderson, Bennet, and Sheldrake, 1999). While efforts
have been made to expand discourse into homosexual populations (Higgins
and Hynes, 2018: 3), most of this research focuses on addressing disparities in
LGBT youth rather than sexual experiences and preferences of adult popula-
tions (Fredriksen-Goldsen and Muraco, 2012: 407; Harding et al., 2012: 68;
Knochel et al., 2011: 371). Chapter 14 addresses sexual orientation in greater
depth. The recent anthropological approaches offer nuanced explorations of
emic constructions of sex.
Included among the sexual behaviors reported for heterosexuals, regard-
less of marital status, are vaginal, anal, and interfemoral intercourse (the
penis is placed between the partner’s thighs); cunnilingus (oral stimulation
of the vulva); fellatio (oral stimulation of the penis); masturbation (sexual
self-stimulation); and mutual masturbation (stimulating one’s partner’s gen-
itals usually manually) (Davis and Whitten, 1987: 73; Herdt, 2006). Cross-
culturally, erotic practices between men who have sex with men include oral
and anal sexual practices, mutual masturbation, interfemoral intercourse; and
for women who have sex with women this also includes oral, manual stim-
ulation, “dry humping,” and the use of an artificial penis made of various
materials. Ethnographic information on what women actually do in terms
of behavior and pleasure, particularly with regard to masturbation (Fahs and
Frank, 2014), has been lacking in previous years. However, research in this
field is growing (Goldey et al., 2016; Herbenick et al., 2011 McLelland, 2013).
The meanings of the same-gender sexual behaviors vary widely. For example,
as the Sambia illustrate, although oral insemination occurs as a rite of pas-
sage among young men, it is not equivalent to industrialized “homosexual”
behavior/identity; nor is the Lesotho “mummy-baby” ritualized friendship of
an older and younger woman a lesbian one, although it incorporates erotic el-
ements (Blackwood, 2005a, b). The terms homosexual/lesbian/bisexual/queer
are loaded with Euro-American sentiment. Given the evidence of third and
more genders in many societies, the exportation of industrialized transgender
and LGBTQ identities through globalization and the variety of extant emic
interpretations of sexuality, the appropriateness of the term “homosexual”
just because two bodies have the same genitals must be seriously questioned
(Lancaster, 2003; Nanda, 2000).
What is regarded as erotic in one culture may not be in another. There is
tremendous heterogeneity in virtually every aspect of sexual arousal encom-
passing what is regarded as foreplay, whether it is emphasized in the sexual
repertoires, the sexual positions that are preferred, and what positions are
considered “natural” and unnatural, as well as the embodiment of erotics. For
example, in some societies, breasts are not erotic but the source of food for an
infant. Although the missionary position with the man on top is the most
common position for Euro-Americans, this too is not universal. Other positions
Adult Sexuality 283
for heterosexual intercourse include the Oceanic position, which involves the
man squatting between the thighs of his partner with her legs straddling his
thighs; another position preferred in some African and Native American so-
cieties is lying side by side, face-to face (Gregersen, 1994). Gregersen (1994:
62–70) summarizes a number of additional positions described in the ethno-
graphic record. These include:
• Man lying, woman squatting, face-to-face, woman on top.

• Rear entry.
• Man sitting, woman squatting, face-to-face, woman on top.
• Standing (worldwide this position is usually associated with brief encoun-
ters with “illicit” partners).
Colonization, missionization, globalization, and the Internet have influenced

the conceptions of the erogenous as well. For example, kissing is not universally
recognized as erotic behavior. While kissing is widespread in industrialized
countries, the Middle East, and among Hindu groups, for others such as those
in Japanese and Chinese societies, kissing was not in the sexual repertoire
until contact with industrialized society (Ford and Beach, 1951; Gregersen,
1994; Tiefer, 2004). Cross-culturally, in the smell or olfactory kiss, the nose is
placed on the partner’s face as one inhales; nose rubbing may be a variant of
this kind of kiss reported among Inuit and others (Gregersen, 1994).
The Mangaians, a Cook Island society, offer a classic example of the com-
plexities of a society that generally valued sexuality in a very positive way.
Marshall, who initially conducted his research in the 1950s, argued that un-
derpinning this positive ethos is evidence of some cultural ambivalence. Two
examples of this patterned ambivalence were:
• A cultural emphasis on the genitalia and intercourse was contrasted with

rigid rules of modesty for adults.
• Rich oral traditions with explicit stories of intercourse were juxtaposed by
sexual norms that sanction parents and children from talking about sex
with each other.
One of the many ways Mangaian society culturally elaborated sexuality is

through attention to the genitalia. An emphasis on pleasure was bolstered
with considerable sexual knowledge about the genitals, expressed in an elabo-
rate taxonomy of terms for the size, shape, and consistency of the genitals. The
linguistic elaboration incorporated a lexicon for classification of the clitoris
that included degree of sharpness or bluntness as well as terms for specific areas
on the penis unclassified in the lexicon of English speakers.
Prior to marriage, youths were encouraged to have as many partners as pos-
sible, similar to Mead’s controversial claims regarding the sex lives of Samoan
adolescent girls. Marshall (1971) reports that Mangaian youths in their teens
and twenties may have had intercourse as many as eighteen to twenty times a
284 Adult Sexuality
week. Although coitus was emphasized over foreplay, the latter incorporated
manual and lingual caressing of each other’s nipples, cunnilingus and fellatio
as well as “dirty talk” by the male to make his partner hotter. Despite this vari-
ety, the foreplay was typically only about five minutes long. Mangaian attitudes
toward sex centralized the activity of penile-vaginal intercourse, emphasizing
lots of pelvic action for both women and men, and valuing the ability of a man
to prolong the in-and-out of coitus. Mangaian erotics accentuated the woman’s
sexual satisfaction and valorized a man’s responsibility in facilitating multiple
orgasms in his partner. The Mangaian masculine ideal was for his partner to
have two or three orgasms to his one. Intimacy and affection were considered
a possible but not an invariable prerequisite for sex, as in the Euro-American
relational view of sex for women.
The Mangaians are not unique in their development of a positive and elab-
orate approach to sex. While Mangaians’ sex education during the period of
Marshall’s research occurred through oral conventions as is typical of many
nonliterate indigenous societies prior to colonization, missionization, and
globalization, other societies with writing traditions may accent texts for sex
education. For example, India has a very old and complex tradition of sexol-
ogy exemplified in texts such as The Kama Sutra (The Precepts of Pleasure by
Vaatsyaayana), written between 200 and 400 AD (Gregersen, 1983: 32). Please
note that there are several spellings of this text. Through Euro-American eyes,
the Kama Sutra appears to be in the genre of a sex manual or text. However,
there are some very important distinctions between texts such as the Kama Sutra
and industrialized sex manuals. Although the Kama Sutra includes chapters on
sexual positions and pleasure, it also incorporates discussions on issues in human
relations, ethics, and living a sacred life. In Euro-American sexology, sex man-
uals have been secularized by a scientific approach; we look to science for the
“truth,” and we separate the sacred and the profane. By contrast, in India, the
Kama Sutra was considered a testimonial of the gods (Gregersen, 1994).
The book describes 529 possible positions for intercourse, categorized
women by depth of the vagina and men by penis size, as well as offers some
helpful hints on how to enlarge the penis. While the number of positions may
seem high, many consist of only minor variations in position (Gregersen, 1994:
62). The Kama Sutra was a widely accepted text representing various themes
in Hindu ideology. Hinduism generally incorporates a positive approach to
sexual expression that is framed by Hindu ideologies that blend the sacred
and the profane, uniting the spiritual with the erotic in ways that are anoma-
lous to Judeo-Christianity. For example, the themes of righteousness and spir-
ituality (the sacred) are merged with the profane elements of prosperity and
pleasure (Bodley, 2005; Francoeur, 1991c; Gregersen, 1994). Sexual love and
pleasure are one of the ways to achieve spiritual knowledge (Francoeur, 1992;
Garrison, 1983). Since the Vaatsyaayana writing, Hinduism has incorporated
some sex-negative attitudes as a result of influences from Islam and the co-
lonial/post-colonial encounter. Globalization and the Internet, however, are
influencing younger people’s attitudes in more sex positive directions.
Adult Sexuality 285
Hinduism is a complex and heterogeneous religion with many sects, diverse
and historical trajectories, and consequently, a panoply of views of sexuality
evolving over the course of 3,500 years (Bodley, 2005). Several sects within
Hinduism have specifically regarded sexuality as a means to reaching spiritual
union with the higher powers of the universe. We shall focus on one of those
sects, Tantra. Tantric traditions existed prior to the advent of Hinduism in In-
dia. As Hinduism developed and spread, Tantric philosophies were adopted into
branches of Hinduism as well as Buddhism (Francoeur, 1991a; Parrinder, 1996;
Urban, 2003). Tantric schools that are associated with Buddhism have devel-
oped their own unique direction; our discussion focuses specifically on Hindu
Tantrism (Devi, 1977; Francoeur, 1992; Gregersen, 1994). Despite a flourishing
of Indian Tantrism during the eleventh and twelfth centuries, it remained a
somewhat marginalized sect because of conflict with wider Hindu beliefs against
eating meat, having sex with a woman who was menstruating, and the violation
of caste prescriptions in certain Tantric sex rituals (Devi, 1977). Despite this
history, it is still practiced in parts of India today (White, 2003).
In Tantric doctrines sexual expression is regarded as a religious experience
and a vehicle to achieve transcendence. Maithuna, or the sexual union, is a
way to approximate merging with the sacred. This contrasts sharply with the
mind-body dualism of Christianity that views chastity/celibacy as the ultimate
sacred experience, while sex is relegated to the profane. Sex is tolerated in
some of the more fundamentalist Christian sects provided it is heterosexual
marital intercourse for procreation. While there are Hindu doctrines that also
value celibacy as a virtue, these occur for different reasons than in Judeo-
Christianity; for example, they emphasize concerns over ritual pollution and
the belief that because semen is a source of male health, it must be controlled.
These doctrines supporting celibacy are generally inconsistent with various
Hindu versions of Tantrism.
Tantrism follows the teachings of books called Tantras. The oldest Tantra is
part of the Hindu sacred text known as the Vedas. In the Tantric worldview,
sex is much more than a physical experience; it includes the process where
men and women can achieve a sense of common humanity or “communitas”
(Turner, 1969). Through sexual union, a woman and a man can transcend
their masculinity and femininity to recognize the qualities of the other gender
in themselves and thereby gain access to her or his spirit being. In this way:
A doctrine of primal androgyny also pervades the Tantric approach: a

male seeks out a female and the female a male, because they do not know
that the opposite sex is lodged within their own being. To realize this fully
is important for the future life.
(Gregersen, 1983: 222)
The power of the universe is expressed through two oppositional forces: the
static inertia of the female and the dynamic inertia of the male. Spiritual power
is created through the union of these opposite cosmic forces. This creates a
286 Adult Sexuality
primal energy that can lead to spiritual perfection resulting in a sacred unity
called prana (Garrison, 1983: 7).
In contrast to industrialized concepts of heterosexual sexual expression as
having only two phases, foreplay and intercourse, the Tantric texts view sex as
occurring in multiple phases. These include (Devi, 1977):
• Having one’s thoughts dwell on sex.

• Spending time with the other sex.
• Flirting.
• Intimate conversation.
• Desire for coitus.
• Firm determination.
• Physical copulation.
These phases illustrate the central principle of Tantrism as a form of sacred “wor-
ship [that] is through the flesh, with body and mind” (Devi, 1977: 16). Conse-
quently, coitus is regarded as a vehicle for creating a sexual energy that leads to
religious ecstasy. Tantric philosophies of sexuality differ considerably from prom-
inent perspectives in Christianity. St. Augustine of Hippo is credited with infus-
ing Christianity with negative sentiments about sexuality. In his interpretation,
the Garden of Eden is the locus of original sin. Because Adam and Eve defied
the authority of the creator god by discovering sex, that sin was passed on to all
of humankind. Although sex was regarded as necessary for procreation, sexual
desire and arousal were thought to be sinful. The story of Adam and Eve provides
the framework for establishing a rationale for regulating sexual behavior, gender
relations, and marriage. As opposed to the Tantric perspective of sex as sacred,
in Christianity celibacy became the exalted state because the original sin of sex
meant a fall from grace. In industrialized worldviews, heavily influenced by
Judeo-Christianity, sex is located in the body, distinct from spirit and mind
(Tiefer, 2004: 24). According to Francoeur (1992: 7): “Christianity, for the most
part, has not been able to integrate sexuality into a holistic philosophy or see sex-
ual relations, pleasure, and passion as avenues for spiritual meaning and growth.”3
The traditional practitioners of Tantrism in nonindustrialized societies

are very diverse; some incorporate more conservative approaches to sex-
ual rituals. However, in the United States and Europe, a modern or neo-
Tantric tradition proliferates in a truncated form which may emphasize
the sexual-spiritual connection or take a sexual therapy/self-help approach
emphasizing Tantric techniques to improve performance and pleasure
(Kuriansky, 2005; Urban, 2003).
Theories of Sexology in Industrialized Society

Twentieth- and twenty-first century industrial theories of human sexual re-
sponse (HSR) have been modified as a consequence of socio-cultural change,
Adult Sexuality 287
especially with regard to gender roles. In this section we shall focus on some, but
certainly not all, of the sexologists who have influenced the study of human sex-
uality. The history of Euro-American sexology testifies to the shifting definitions
of human sexual response over the course of time. While we will emphasize
research spanning the last century and the current one, many of these perspec-
tives were influenced by earlier thinking on the subject of human sexuality.
Freudian theory dominated sexology until Kinsey and his colleagues ushered
in a new era of scientific sexology devoted to challenging myths about sexu-
ality by collecting data on sexual practices in the United States. One of the
major changes in the discipline of sexology has been in how women’s sexuality
was regarded. The Freudian view emphasized women’s sexuality as a passive
expression in contrast to men’s sexuality, which was interpreted as essentially
important, active, assertive, and dominant. Freud’s account of the gendering
of sexuality was interrogated first by Kinsey, Pomeroy, and Martin (1948: 1053)
and followed by other researchers such as Masters and Johnson (1966), Singer
and Singer (1972), Kaplan (1974, 1979), and Perry and Whipple (1981) whose
research affirmed women’s capacity for sexual arousal and pleasure. As a con-
sequence, these researchers transformed the discipline of sexology from one
that had emphasized gender differences in human sexual response as a result of
Freud’s legacy, to one that argued that women’s and men’s sexual responses were
more alike than disparate. Although the assumption of gender concordance in
human sexual response continues as a major theme in contemporary sex re-
search, it has been challenged by researchers who underscore the importance
of culture, history, and context in how women and men subjectively experience
their sexuality (Castro, 2001; Gagnon, 1977, 2004; Herdt, 2004; Kaschak and
Tiefer, 2001; Parker, 2000; Tiefer, 2004 among numerous others). Although sex-
ual behaviors among US women and men have been converging over time and
becoming more similar, such as rates for teenage intercourse, premarital inter-
course, and number of partners, the debate has centered on the issue of sexual
response (Laumann et al., 1994). The essentialist paradigm argues for a “unisex”
model of human sexual response while the constructionist paradigm asserts that
although women’s and men’s sexual behavior and responses may appear similar,
their sexual experiences including sexual interest, desire, and arousal are diver-
gent because of their gendered positions and relations in society. Ethnocentric
biases and assumptions about heterosexuality (monogamy, serial, or lifelong)
and the potential for reproductive success clearly circumscribe these approaches,
eliding the voices from diverse sexual cultures.
The 1960s marked an era of massive social unrest and discontent. The sec-
ond Sexual Revolution (the first occurring in the 1920s with a sharp increase
in premarital sex for women) was officially under way by the mid-1960s. The
media credited youth with engagement in a socio-sexual transformation, al-
though some scholars questioned whether a Sexual Revolution had occurred
at all, since:
Put briefly, men changed their sexual behavior very little in the decades
from the fifties to the eighties. They “fooled around,” got married, and
288 Adult Sexuality
often fooled around some more, much as their fathers and perhaps their
grandfathers had before them. Women, however, have gone from a pat-
tern of virginity before marriage and monogamy thereafter to a pattern
that much more resembles men’s…
(Ehrenreich, Hess, and Jacobs, 1986: 2)
Nevertheless, trends for democratizing sexuality were preceded by the women’s

movement by two or three years, implicating the influence of feminist trends
for gender role parity in sexuality (Ehrenreich, Hess, and Jacobs, 1986). By the
late 1960s, issues of “sexual freedom” were integrated with second wave feminist
concerns for women’s equality and expressed in arguments advocating women’s
sexual and reproductive rights. Central to second-wave feminist thinking was
the perspective of sexual politics—that inequality between women and men was
not just a public social problem, but a private one as well. This could be located
in the intimate and sexual relations between women and men, where inequities
even pervaded the bedroom. The rumblings of the Women’s Movement contrib-
uted to a separation of sex from marriage and reproduction, enhanced by the
widespread availability of the oral contraceptive pill that was developed in the
1950s and granted FDA approval in 1959. The 1960s and 1970s were punctuated
by the “hippie” counterculture, whose ideology of “free love” and normalizing of
premarital sex infiltrated the youth culture of wider US society. By the end of the
1970s, researchers found few gender differences in premarital sex and as D’Emilio
and Freedman argue, “American society seemed to have reached a new accom-
modation with the erotic” (1988: 300; Ehrenreich, Hess, and Jacobs, 1986: 40).
Since the 1980s and continuing into the new millennium, the United
States has witnessed a tremendous backlash to the gains women have
made regarding their reproductive rights to control their fertility (Faludi,
1991; Herdt, 2004; Kimmel, 2000). This backlash was extended more
widely under the Donald Trump administration through promotion of
“abstinence-only” approaches to sex education domestically and inter-
nationally as well as federal policies aimed at banning abortions and
defunding Planned Parenthood. We encourage the reader to be alert to
changes in policy over time and with different administrations and to
pursue reputable government and scholarly sources for updates subse-
quent to the publication of this textbook.
The meaning of sex was also reformulated as a consequence of the social up-
heavals heralded by the 1960s. Masters and Johnson (1966) demonstrated that
women’s sexuality was more extensive than previously thought, so that sex
came to include more than just penile-vaginal intercourse for heterosexual co-
itus. The importance of the clitoris in female sexual response was one factor in
this new view. The definition of sexuality was expanded to include additional
Adult Sexuality 289
behaviors such as cunnilingus, which was only whispered about in the 1950s.
Populist currents for the democratization of sex were felt as Freudian theory
began to lose some of its foothold and popular sex books appeared. Sex experts
sprang up everywhere during the 1960s and 1970s including: J’s The Sensu-
ous Woman (1969), Comfort’s The Joy of Sex (1972), Friday’s My Secret Garden
(1974), and Hite’s The Hite Report (1976).
With these books, a more humanistic trend evolved that offered sexual
advice as the changing meanings of female sexuality were being felt in the
bedroom (Ehrenreich, Hess, and Jacobs, 1986). These popular accounts were
not scientific and were not based on the principles of sound research method-
ologies, but, in all fairness, this was not their purpose. Rather they represented
a trajectory in the “democratization” of sex, which was a popular genre that
would coexist with current proclivities for scientific and empirical research
initiated by Kinsey and coupled with newly emerging medical and scientific
perspectives of the 1960s such as that of Masters and Johnson (1966).
Sexological research is not only a product of history and culture (i.e., re-
produces culture); it also contributes to the wider sexual culture of our times
and place (produces culture) defined as the “intrinsic or internal meaning, as
well as extrinsic or environmental sources of sexual behavior” (Herdt, 1999:
100). Though the media plays an ever-increasing role in sexuality nationally
and globally, the scientific literature is also part of the diverse ways that sex
is framed and “spun” (Gagnon, 2004). In the following sections we review the
contributions of selected researchers in the field of sexology. By no means is
this meant to be an exhaustive review; rather it highlights several of the most
prominent theorists and their significant influences on sexology in the twenti-
eth century and the new millennium.
Freud
Freud had a tremendous impact on sexological thinking up through the 1950s.
As discussed in Chapters 2 and 10, Freud’s theory of psychosexual development
emphasized phases in childhood and adolescence and the importance of the Oe-
dipus complex. For Freud sexuality was the cornerstone of his psychoanalytic
approach (i.e., adult sexuality is determined by childhood psychosexual develop-
ment). Freud regarded male sexuality as the norm against which he judged wom-
en’s sexuality as more timid and passive, as well as inherently more problematic.
In his 1905 book, Three Essays on the Theory of Sexuality, he identified two types
of female orgasms. The clitoral orgasm was regarded by Freud as an immature one
centered on the erogenous zone of the clitoris, and related to girls’ experiences
with masturbation. In contrast, the vaginal orgasm was considered the mature
form of orgasm, associated with reproduction. This shift from clitoral to vaginal
orgasm occurred after puberty as the vagina became the central foci of women’s
sexuality. In Freud’s view, women who experienced sexual pleasure in ways other
than through penile penetration were immature and fixated in an earlier phase of
development (Bullough, 1994; Byer and Shainberg, 1991: 186; Freud, 1975 [1922]).
290 Adult Sexuality
Critiques of the Freudian approach are numerous, but the most often cited
charges address the issue that the psychoanalytic approach is not subject to sci-
entific methods of verification since Freud’s theories emerged from his practice,
and he offered no systematic data per se. He only treated 130 patients, none
of whom were children. In addition, his perspective on women’s sexuality has
been denounced as androcentric (Westheimer and Lopater, 2005).
Kinsey
In 1948 Alfred Kinsey and his colleagues published the Kinsey Reports on
male sexuality (Sexual Behavior in the Human Male) followed by 1953’s Sexual
Behavior in the Human Female. Their work had a profound impact on the sci-
entific community as well as on US conceptions of sexuality. Although Kinsey
and his collaborators’ contributions are many, we shall highlight a few of the
most significant findings about American sexuality. In contrast to Freud’s psy-
choanalytic perspective that stressed the differences between female and male
sexuality, Kinsey concluded male and female sexuality were much more alike
(Ehrenreich, Hess, and Jacobs, 1986), which is a surprising view of sexual-
ity given that their research occurred in the context of the post-WWII baby
boom. Thus, their position, that there were few differences in male and female
orgasm and human sexual response, contradicted not only the legacy of Freud
but the popular gender culture of the times that was in the midst of celebrating
gender difference as essentialistic.
The Kinsey approach to human sexuality was dedicated to scientific rigor
that emphasized the behavioral, although critics have argued that it left the
affective and experiential component of sex unrecognized. Despite back-
ground training as a zoologist, Kinsey emphasized a sociological approach to
measurement, analyzing data using gender, age, education, and marital status
as variables in understanding sex as a “natural” and essential drive (Giami,
2005). Kinsey’s passion and mission were devoted to ending sexual ignorance
by using the scientific method to collect data on people’s sexual experiences
that could subsequently be quantified into behavioral terms. Sexual Behavior
in the Human Male was based on 12,000 case histories and Sexual Behavior in
the Human Female was based on 8,000. Although detractors have focused on
Kinsey and his colleagues’ lack of attention to sexual meanings and culture,
this was not indeed the objective of their research. Kinsey was a dedicated pro-
ponent of sexuality education, hoping to end sexual ignorance and mythology;
he brought to the United States a much needed culturally relativistic approach
to sexual behavior (Lyons and Lyons, 2004).
Betty Friedan, an early feminist and author of The Feminine Mystique (1963)
(Ehrenreich, Hess, and Jacobs, 1986: 43), criticized the Kinsey reports for pre-
senting sexuality “as a status-seeking game in which the goal was the greatest
number of ‘outlets,’ [or] orgasms.” Ehrenreich and colleagues (1986) suggest
that Kinsey’s dedication to an evidence-based scientific sexology that could be
quantified had a profound influence on America’s conceptions of sexuality by
Adult Sexuality 291
shifting the focus to the number of orgasms. He has been accused of bias in his
statistics due the number of male prisoners in the first book and for reliance on
volunteers in both volumes (Lyons and Lyons, 2004).
Despite these critiques of his/and his colleagues’ work, Kinsey made a huge
contribution to creating the emergent discipline of sexology and influenced so-
ciety at large by confronting traditional attitudes toward sexuality (Bullough,
1994, 2004). Kinsey and his colleagues offered a new sexual paradigm for main-
stream US culture that normalized and familiarized homosexuality, masturba-
tion, premarital sex for men and women, heterosexual coitus, and extramarital
affairs by making them topics of conversation in popular culture (Bullough,
2004; Giami, 2005). Kinsey may be credited with establishing the survey as a
method for understanding US sexual practices that has continued today, al-
beit with more rigor. See the discussion of Laumann and colleagues’ research,
which follows.
The Kinsey Institute at the University of Indiana persists today as Kinsey’s
legacy. This institute continues to promote and fund sexuality research, creat-
ing new opportunities for interdisciplinary sex research and education as well
as housing a massive archive of print, film and video, fine art, artifacts, and
photography.
Masters and Johnson

William H. Masters and Virginia E. Johnson continued Kinsey’s efforts to de-
velop a scientific sexology. Their research emphasized an innovative approach
to the collection of data on human sexual responses during sexual stimulation.
This was achieved through controlled observations in a laboratory that in-
tegrated various medical technologies to measure physiological indicators of
human sexual response (Masters and Johnson, 1966). Masters and Johnson’s
research was initiated in 1954 and resulted in the publication of the now fa-
mous Human Sexual Response (1966).
Recognized as much for their research methods as their findings, Masters
and Johnson incorporated married and unmarried participants in their study;
women ranged in age from 18 to 78 (n = 382) and males’ ages were from 21 to
89 (n = 312) (Masters and Johnson, 1966: 12–13). Though offering significant
contributions to sexology, their research subjects were overrepresented by those
with formal education and biased in regard to class, economic privilege, and
race/ethnicity. Of the non-Caucasian research population, only eleven family
units were African American (Masters and Johnson, 1966: 12–15), nor was the
homosexual data they collected presented in their final research (1966).
The research setting (a laboratory) allowed for direct observation and mea-
surement of physiological changes and responses during a variety of sexual
activities including manual and mechanical manipulation and intercourse in
different positions (Masters and Johnson, 1966: 21). Their clinical and high-
tech methods included artificial coital equipment (artificial penises) equipped
to measure female sexual response, as well as various kinds of monitors to
292 Adult Sexuality
measure genital and other physiological responses. The clinical procedure was
enhanced by in-depth interviews.
Masters and Johnson documented and established four phases in the human
sexual response cycle (HSR): excitement, plateau, orgasm, and the resolution
phase (Masters and Johnson, 1966: 4). Over the eleven years of their study they
observed over 10,000 sexual acts of married and unmarried people from ages
eighteen to eighty-nine. As a result of their extensive research, they concluded
that males and females had the same physiological responses in the HSR cycle,
although women had more varieties of sexual orgasms than men and could be
multi-orgasmic (Bullough, 1994). Variations in this four-stage model included
some gender differences. Male response cycles varied among individuals pri-
marily along the dimension of duration of response, while females differed by
duration and intensity.
The excitement phase is characterized by vasocongestion defined as en-
gorgement of the blood vessels in the pelvic region and increased muscle
tension. In women, lubrication of the vagina occurs in association with the
swelling of erectile tissues including clitoris, labia, vaginal opening, and in
men this is associated with penile swelling.
The plateau stage precedes orgasm and varies in duration. In males, full
erection and engorgement of the testes are reached. In females, the vagina ex-
pands and lengthens as the uterus gradually elevates. The orgasmic platform
is reached during this stage in which the vaginal opening is reduced in size
because of engorgement of the surrounding erectile tissues (Bullough, 1994;
Byer and Shainberg, 1991: 182; King, 2005).
Orgasm marks the third stage. The female orgasm is characterized by three
to twelve contractions at 0.8 second intervals (Francoeur, 1991a: 182; Hyde,
1985: 278). While the female orgasm lasts for thirteen to fifty-one seconds,
the male orgasm lasts from 10 to 30 seconds (in Francoeur, 1991a: 182) and
is usually, but not inevitably, associated with ejaculation. As noted, orgasm
was found to vary among women, with some capable of multiple orgasms and
others not. These occurred sequentially during the orgasm stage without the
woman returning to plateau levels (McAnulty and Burnett, 2003). Orgasm
and ejaculation are physiologically distinct. It is possible for men to experience
orgasm without ejaculation before puberty, in old age, after prostate surgery,
and in some cases of erectile disorders.
The final phase of human sexual response is that of resolution. This is the
process where blood is released from the engorged areas, muscle tension is
relaxed, and the body returns to its previous state. For the female, this process
may last up to half an hour if orgasm occurred, or an hour if only the plateau
stage was reached (Masters and Johnson, 1966).
During resolution men experience a refractory period where sexual stimula-
tion will not produce another erection. It has been argued that the refractory
period is what prevents men from having multiple orgasms. Reports of multiple
orgasms in men are still controversial and undoubtedly clouded by definitional
interpretation. Self-reports of multiple orgasms in Kinsey, Pomeroy, and Mar-
tin (1948) are defined as occurring during one sexual encounter. In the Kinsey
Adult Sexuality 293
data, 15–20 percent of the teenage boys reported multiple orgasms with only
3 percent of the subjects claiming this ability after the age of sixty. Masters
and Johnson maintain that once ejaculation has occurred it is not possible
for a man to experience orgasm without a refractory period. However, there
is some suggestive evidence around this issue. For example, Dunn and Trost
(1989) have reported on multiple orgasms in twenty-one men who experienced
a variety of orgasms; some had one or more dry orgasms before ejaculation and
others experienced these after ejaculation. Men’s reports of multiple orgasms
may be part of the incredible variation in how humans experience sexuality.
Multiple orgasms in men illustrates the tremendous difference in the individ-
ual experience in human sexual response (King, 2005).
Masters and Johnson discredited the dominant Freudian view that there
were two kinds of orgasms possible for women: the clitoral and vaginal. In
the Freudian view, a woman was doomed to vaginal frigidity if she could not
make the transition from the childish/immature clitoral orgasm to the mature
vaginal one. Masters and Johnson argued that there was no purely vaginal
organism and that the clitoris was central in the female orgasm whether from
indirect stimulation during coitus or through direct stimulation. Ehrenreich,
Hess, and Jacobs (1986) points out that this was not really news since earlier
research demonstrating this had been available “for decades,” although the
psychiatric doctrine had been tenacious in sticking to the Freudian view.
In addition, Masters and Johnson also verified women’s capacity for multiple
orgasms and challenged the myth that women’s orgasms were like men’s in
requiring a refractory period prior to a subsequent orgasm(s). As early as 1953,
Kinsey et al. had reported that 14 percent of the female population in the
United States was capable of multiple orgasms. Masters and Johnson found
that women’s multiple orgasms were no different than their single ones.
Masters and Johnson’s detractors criticized their research for the same
reason as Kinsey’s; that is, they had “reduce[d] human sexuality to physical re-
sponses, though, of course, only physical responses are accessible to quantitative
measurement” (Ehrenreich, Hess, and Jacobs, 1986: 66). This model of human
sexuality has been denounced for its androcentric bias with its focus on pene-
tration and orgasm as well as being one-dimensional in scope (Basson, 2005;
Francoeur, 1993: 72; Tiefer, 2004). In addition, Masters and Johnson’s research
methods have been critiqued for sampling bias in the research population; it
was preselected for coital and masturbatory experience as well as higher SES
(socio-economic status). Tiefer (2004: 43–61) has further criticized Masters and
Johnson’s human sexual response cycle, regarding it as reductionistic in its un-
wavering universal stages; offering a view of human sexual response as confined
and fragmented into physiological parts; and emphasizing sexuality as a primar-
ily genital experience as opposed to a whole body response. Although Masters
and Johnson’s research asserts that women and men have similar physiological
responses, it ignores the wider socio-cultural context of gender relations (e.g., the
relational and recreational models of sex that are still pervasive in US society)
and the influence of the experiential component of sexuality. (See discussion on
Tiefer, and the section “Problems in sexual response.”)
294 Adult Sexuality
Masters and Johnson are also known for their study of problems in human
sexual functioning. In 1970 they published Human Sexual Inadequacy.
Their therapeutic approach was distinctive; they treated couples rather than
the individuals; utilized a behaviorist model rather than a psychoanalytic one;
and boasted high success rates through short-term psychotherapy.
Singer and Singer

In 1972, Singer and Singer offered another model of female sexuality that in-
cluded three kinds of orgasms: the vulval orgasm (described by Masters and
Johnson), the uterine orgasm, and the blended orgasm. The blended orgasm
combined the vulval and the uterine types. Singer and Singer’s evidence in-
volved the possibility of women experiencing orgasm without “vulval contrac-
tions” or, in Masters and Johnson’s terminology, contractions of the orgasmic
platform (Singer and Singer, 1972: 256). Their research seriously challenged
Masters and Johnson’s clinical research on women’s orgasms by suggesting a
greater range of variation. Although they concurred with Masters and John-
son that women’s vulval orgasms are a result of either direct or indirect clitoral
stimulation, they described another type of orgasm that they labeled the uter-
ine orgasm. According to Singer and Singer (1972: 259–260):
the “uterine orgasm” does not involve any contractions of the orgasmic
platform… this kind of orgasm occurs in coitus alone, and it largely de-
pends upon the pleasurable effects of uterine displacement. Subjectively
the orgasm is felt to be deep, i.e., dependent on repeated penile-cervix
contact.
This orgasm is characterized by interrupted breathing with the orgasm and the
expulsion of breath occurring simultaneously (Singer and Singer, 1972: 260).
The blended orgasm combines characteristics of both the vulval and the
uterine orgasm. It incorporates contractions of the orgasmic platform but is
experienced as deeper than a vulval orgasm and more akin to the uterine in
that breathing is interrupted (Singer and Singer, 1972: 260). The same cri-
tique of Masters and Johnson has been applied to this research. While Singer
and Singer expanded Masters and Johnson’s perspective on women’s orgasms,
similarly their research suggests a “biological uniformity” that underrates the
complexity of how meanings and symbols, culture and context can influence
the individual’s experience of sexuality (Tiefer, 2004).
Kaplan
Helen Singer Kaplan wrote extensively on the subject of human sexuality
(1974, 1979, 1983, 1989) and was known for her modification of Masters and
Johnson’s four-stage human sexual response cycle. Kaplan (1979) remodeled
Adult Sexuality 295
the human sexual response cycle into three phases. She added “desire” as a
precursor stage to arousal defining it as the specific “sensations” that lead to
an interest in having sex. The addition of “desire” has earned her the most ac-
claim in contributing to an understanding of human sexual response. She cat-
egorized the second phase in human sexual response as the “arousal” phase
in which she collapsed Masters and Johnson’s excitement and plateau phases,
followed by orgasm. For Kaplan sexual desire was considered an appetite or
drive motivating sexual behavior. Other researchers more recently have em-
phasized the socio-cultural and relational parameters of desire (DeLameter and
Sill, 2005). The stage of desire has been integrated into the human sexual
response cycle in the Diagnostic and Statistical Manual of Mental Disorders,
a compendium of the Euro-American nosology of mental distress and is re-
garded as one of the categories of sexual disorders. (See section “Problems in
sexual response” for further discussion.)
Unlike Kinsey and Masters and Johnson, Kaplan proposed that female and
male sexuality were distinctive. Subscribing to theories of the biological basis
of sex differences, Kaplan believed that these different sexualities are due to
testosterone, which she argued accounted for a much stronger sexual drive in
males than in females. In contrast to men, the female sex drive was shaped
to a greater degree by lived experience in Kaplan’s view. Kaplan felt that cli-
toral stimulation was essential to female orgasm and that vaginal intercourse
alone would not necessarily result in an orgasm without additional clitoral
stimulation (King, 2005). According to Klein (1981: 73–75, 77, 92), Kaplan
also regarded humans as monogamous pair bonders, although she left open the
possibility that it may be serial. While offering a more complex view of human
sexual response, this model has been subject to the same appraisal as that of
Masters and Johnson—that of reducing human sexual response to physiologi-
cal indicators at the expense of the personal, cultural, and contextual. Though
contributing to knowledge of the physiology of sexuality, the HSR cycle as
conceived by Masters and Johnson, Singer and Singer, and Kaplan does not
consider the tremendous variety in individuals’ sexual arousal (McAnulty and
Burnette, 2003; Tiefer, 2004). Kaplan also made an important contribution to
sexology through her earlier work on sexual dysfunction. In The New Sex Ther-
apy: Active Treatment of Sexual Dysfunction (1974), she synthesized Masters
and Johnson’s behaviorist approach to sexual dysfunction with psychoanalysis.
Unlike Masters and Johnson’s therapeutic model based on symptoms, Kaplan’s
integrated concern for interpersonal interaction with an emphasis on the un-
conscious (Fischer and Eisenstein, 1984: 143; Kaplan, 1979, 1974).
Whipple and Perry—the “G-Spot” Controversy (Ladas)

The Grafenberg or G-spot is located approximately one or two inches in-
side the opening of the vagina on the anterior wall about halfway between
the outer labia and the cervix. It is named after Dr. Ernst Grafenberg (1950)
who first located and described the dime-sized spot in a 1950 report. In their
296 Adult Sexuality
book The G-Spot and Other Recent Discoveries about Human Sexuality (1982),
Ladas, Whipple, and Perry proposed that the G-spot is an area of sensitive
tissues that when stimulated may lead to orgasm. This research initiated a
controversy that remains relevant today regarding whether the G-spot actu-
ally exists as a distinctive physiological area and if it does whether or not it is
universal among females (Kilchevsky et al., 2012: 720). Research has indicated
that the G-spot may not be universal to all females, but present in only about
10 percent or less of the population (Altzate and Londono, 1984; Masters,
Johnson, and Kolodny, 1985). However, The Federation of Feminist Women’s
Health Centers (A New View of a Woman’s Body, 1995: 39, 162) names and de-
scribes this area as the urethral sponge, a sheath of erectile tissue around the
urethra which becomes engorged during sexual excitement and protects the
urethra during sexual activity. Others have found this area to be responsive to
stimulation as well including the work of Zaviacic and colleagues in Czecho-
slovakia (1987, 1988). Although the evidence is currently inconclusive from
the clinical vantage (Hines, 2001; Whipple, 2006), it is testified to in women’s
self-reports, discourses, and narratives.
The G-spot is important for another reason since Ladas and colleagues con-
tended that it is involved in one of three possible kinds of orgasms in the
female human sexual response cycle. Ladas, Whipple, and Perry proposed that
there are three kinds of female orgasms: tenting, A-frame and blended. The
tenting orgasm occurs with clitoral stimulation. This is like the orgasmic plat-
form of Masters and Johnson. The vaginal entrance restricts and “tenting”
occurs when “the inner portion of the vagina often balloons as a result of the
lifting up of the uterus inside the abdomen” (1982: 144–145). The A-frame
orgasm is quite distinctive in occurring as a consequence of stimulation of the
Grafenberg spot. This type of orgasm includes no orgasmic platform, rather
“the vaginal musculature relaxes and the entrance opens” (Ladas, Whip-
ple, and Perry, 1982: 144). The tenting is absent so that “the uterus seems
to be pushed down and the upper portion of the vagina compresses” (Ladas,
Whipple, and Perry, 1982: 145). The third type is classified as the blended
orgasm. This response involves the pubococcygeal muscle as in the tenting or-
gasm and is also similar to the A-frame orgasm triggered by stimulation of the
G-spot, but the focus is on the muscle response in the uterus (Ladas, Whipple,
and Perry, 1982: 150). In 1999, Whipple and Komisaruk point to yet another
kind of orgasm resulting from stimulation of the cervix. At this juncture, we
can consider G-spot orgasm as one of the many diverse ways women experi-
ence sexual arousal and response.
The G-spot research is interesting for another reason. Perry and Whipple
(1981) proposed that during orgasm 10–20 percent of women have the capac-
ity to ejaculate a substance similar to seminal fluid. They have argued that
female ejaculation is most often associated with the G-spot stimulation. This
assertion has been contested by researchers such as Goldberg et al. (1983) and
Belzer, Whipple, and Moger (1984). In an analysis of female ejaculate, Bel-
zer, Whipple, and Moger (1984) found the same enzyme present as produced
Adult Sexuality 297
by the male prostate, only the chemical structure varied. However, Goldberg
et al. (1983) found no difference between female ejaculate and urine. Ladas,
Whipple, and Perry (1982) have suggested that that as many as 40 percent of
women have experienced an ejaculatory substance from time to time. Sub-
sequent research and self-reports of women confirm that indeed it is not a
question of whether some women emit a fluid during orgasm, but rather what is
the nature of the fluid. For some it may be due to incontinence, but for others
the origin continues to be debated (Federation of Feminist Women’s Health
Centers, 1991; King, 2005; Whipple, 2006).
Deborah Sundahl, co-publisher of the women’s erotic magazine for les-

bians On Our Backs (initially 1984) has made several videos/DVDs on
the G-spot and female ejaculation: These are: “How to Female Ejaculate:
Find your G-spot with Deborah Sundahl” (2002); and “How to Female
Ejaculate for Couples” (2003a) (2003b).
Laumann and the National Health and Social Life Survey

Edward O. Laumann is the principal investigator in a massive undertaking by the
National Health and Social Life Survey, a survey of American adult sexual behav-
ior (the University of Chicago, NORC: A National Organization for Research).
The results of this survey have been reported on by Laumann and his colleagues
in numerous publications. These include three books: The Social Organization of
Sexuality: Sexual Practices in the United States (1994) by Edward O. Laumann, John
H. Gagnon, Robert T. Michael, and Stuart Michaels; Sex In America: A Definitive
Survey (1994) by Robert T. Michael, John H. Gagnon, Edward O. Laumann, and
Gina Kolata; and Sex, Love and Health in America: Private Choice and Public Policies
(2000) Edward O. Laumann and Robert T. Michael.
In a 1992 random sample, Laumann and his colleagues interviewed 3,432
English-speaking adults between the ages of eighteen and fifty-nine. They had
a high participation rate, with 79 percent of the population selected choosing
to respond. Their methods included face-to-face interviews, a self-administered
questionnaire, and focus groups. Like earlier surveys, Laumann’s research cov-
ered numerous topics related to US sexual practices including frequency, part-
ners, masturbation, and STIs and offered statistical analysis of the findings. Their
approach emphasized that changes in sexual activity throughout the life cycle
occurred in response to major life course events and the vicissitudes in one’s
social environment (“The National Health and Social Life Survey Summary,”
n.d.). A few of the findings from National Health and Social Life Survey are:
• Age of first of sexual intercourse is better predicted by personal variables

such as age at puberty than ethnicity or socioeconomic status.
298 Adult Sexuality
• Males generally find fellatio more appealing than females do.
• Caucasian women and men prefer cunnilingus more than other ethnic
groups.
• For both genders, sexual satisfaction increases with emotional commit-
ment and relationship exclusivity.
• Problems with sex affect younger women and older men more than other
age-gender groups.
(Michalski, 2002: 156)
In contrast to other sexological research such as Kinsey’s that emphasized the

individual, Laumann and his colleagues accented the sexual dyad (couple) as
the center of analysis and focused on the importance of sexual interaction
(Bullough, 2004; “The National Health and Social Life Survey Summary,”
n.d.). “The National Health and Social Life Survey” has been regarded by
many as the “the most comprehensive nationally representative survey to date,
as in-depth as the Kinsey surveys, but with scientifically sound sampling tech-
niques” (King, 2005: 19). The shortcomings of this impressive and comprehen-
sive effort are that the survey only included English speakers. In addition, the
researchers conceded that their data based on self-reports are always limited
since the degree to which they correspond to actual behavior is unknown.
Tiefer: A Constructionist View of Sexuality

Leonore Tiefer has been writing and publishing since the late 1970s on the
subject of human sexuality from a social constructionist position. Originally
trained as a biologically oriented psychologist, she returned to graduate school
to re-specialize in clinical sexological psychology. According to Tiefer, “In the
1970’s, writings from the Women’s Movement convinced me that the primary
influences on women’s sexuality are cultural norms internalized by women,
reinforced by institutions and enacted in significant relationships” (2004: xiii).
She has also made this argument regarding male sexuality as well, maintain-
ing that ideologies of masculinity and sexuality are unstable and change over
time (Tiefer, 2004: 1986). Along with various colleagues, Tiefer has challenged
the biomedical orientation of Kinsey and his successors such as Masters and
Johnson, whose model of human sexuality frames sex as a purely physiological
response. In contrast, Tiefer defines and locates sexuality in the “personal,
relational, and cultural, rather than physical terms” (Tiefer, 2004: 23). In her
book, Sex Is Not a Natural Act and Other Essays and in numerous other publi-
cations, Tiefer argues that our understandings of human sexology in Western
industrialized society are dominated by a biological model driven by the quest
for an ever more scientific sexology. This results in an approach that fragments
sexuality into particular body parts. In Tiefer’s view, the scientific imperative
with its biocentric approach to understanding human sexuality has short-
changed us into regarding sex as a biological drive/instinct, causing us to miss
the importance of culture in shaping our desires. Tiefer has challenged the
very notion of biological drive as a cultural universal. In this regard she states:
Adult Sexuality 299
So, if sex is not a natural act, a biological given, a human universal, what
is it? I would say it’s a concept, first of all—a concept with shifting but
deeply felt definitions. Conceptualizing sex is a way of corralling and dis-
cussing certain human potentials for consciousness, behavior and expres-
sion that are available to be developed by social forces, that is, available
to be produced, changed, modified, organized, and defined. Like Jell-O,
sexuality has no shape without a container, in this case a socio-historical
container of meaning and regulation.
(Tiefer, 2004: 3)
Her work on sex from an “antinaturalist”/constructionist perspective has co-

alesced with like-minded colleagues into a campaign named and dedicated to
“A New View of Women’s Sexual Problems.” This approach has challenged the
medicalization of women’s sexuality that reduces “sex” to orgasms and offers an
alternative perspective (“Female Sexual Dysfunction: A New Medical Myth:
Current Campaign Activities,” 2006; Kaschak and Tiefer, 2001; Tiefer, Brick,
and Kaplan, 2003). “A New View of Women’s Sexual Problems” is discussed
further in the section “Problems in sexual response.”
Understanding ourselves as sexual, potentially sexual or non-sexual beings
in the early twenty-first century requires attention to understanding US cul-
tural assumptions and ideologies surrounding sexuality, including diverse in-
fluences and disparate and competing discourses such as the media, politics,
science, etc. From a Euro-American perspective, vaginal-penile intercourse is
naturalized as the “definitive heterosexual act.” Yet, such a view is embedded
in assumptions that sex is an instinctual drive because of the human “need”
to procreate (Gavey, McPhillips, and Braun, 1999). In this regard, Parker notes
that a dominant viewpoint in much sex research, but not all, is that culture
“inhibit(s) us from encountering some kind of enduring truth—a ‘cultureless’
model” of sex (2000: 308). This biocentric perspective represents the con-
fluence of Euro-American scientific beliefs as well as popular and media dis-
courses (Lancaster, 2003).
As we continue our discussion of various themes in human sexual response,
the importance of socio-cultural factors in the social construction of sexuality
is emphasized. This viewpoint is an integral part of anthropological perspec-
tives on human sexuality that highlight variation and diversity through time
and across cultures. The biological and physiological basis of human sexuality
is interpreted by individuals through a cultural and historical lens, intersected
by personal and relational experiences. Human sexual desire and pleasure are
biological, psychological, and cultural phenomena that change through time.
Overview of US Sexual Attitudes

The United States has been categorized as a restrictive and sex-negative soci-
ety (Ford and Beach, 1951). This is largely because of a history that has ideal-
ized heteronormative cultural rules (the idea that everyone is heterosexual),
thus reflecting a Judeo-Christian legacy that sanctioned premarital sex and
300 Adult Sexuality
emphasized sex for procreation. However, the nineteenth century ushered
in new meanings of the family establishing the companionate marriage, one
that accentuated modern notions of love and the importance of sharing and
intimacy, diverging from earlier views of marriage that focused on reproduc-
tion and reciprocal roles of men and women. By the early twentieth century,
sexual pleasure and desire came to be seen as core features in how love and
marriage were defined in the United States. This spawned two competing ide-
ologies dominating the twentieth and twenty-first centuries: “[o]ne viewing
sex as legitimate only in marriage, but as a necessary component of marital
happiness, and the other viewing sex as a valid and important experience in
its own right” (Weiss, 2004b: 1136). It has been argued that the huge changes
that have occurred in US sexual practices over the past century are a result of
these countervailing and competing perspectives about sexuality and its role
in society (D’Emilio and Freedman, 1988). Therefore, rather than viewing
the United States as a sex-negative society, we can say it is generally a sex-
ambivalent one (remembering that we are a plural society, with much varia-
tion). Conflicting themes and messages are expressed in an increasing influence
of the Internet and other forms of media, which in turn reflects and reproduces
these contrasting ideologies. These debates continued with the second Sexual
Revolution in the 1960s and 1970s. Changes in sexual attitudes resonated in
bumper stickers, which read, “make love not babies.” Trends for the separation
of sex and reproduction were fueled by the Women’s Movement and the wide-
spread availability of the birth control pill. This has resulted in the increasing
importance on sex for self-expression and pleasure, with the debate framed in
terms of marital versus non-marital sex (Tiefer, 2004).
Ambivalence toward sex is echoed in various institutions and cultural dis-
courses (ways of constructing what we think of as truth including, the media,
medicine, religion, etc.). The double standard, while loosening up dramatically
in the 1970s, has not changed much qualitatively from the 1950s; it has been
revamped into the “conditional double standard, in which males are allowed
more freedom than females to engage in premarital sex, but females are per-
mitted to be sexually active as long as they are in affectionate relationships”
(Sprecher, McKinney, and Orbuch, 1987: 24). An assortment of beliefs and
practices related to sexuality throughout the life course and in different con-
texts testifies to this ambivalence.
Problems in Sexual Response: Diagnosis and Disagreements

In discussing sexual difficulties in the United States, a biological, psychologi-
cal, and cultural lens is necessary to visualize this issue further. As discussed,
oppositional and ambivalent messages about sexuality in the United States
have a historical and current reference to the expression and definition of sex-
ual problems. Bear in mind that the United States is a society spanning di-
verse classes and ethnicities, so our discussion here will necessarily emphasize
broad trends. Sexual problems must be understood as developing in biological,
Adult Sexuality 301
psychological, and cultural context including biological factors such as gen-
eral health, activity level, and medications; psychological factors such as the
individual’s experience, the partner relationship; and cultural factors spanning
a wide range of influences such as societal ambivalence, inequities in gender
relations, differences in sexual knowledge and access to sexuality education,
economic influences, and various dimensions of embodiment including ideals
of beauty, among others. This perspective is typically anthropological, and
includes attention to issues such as sexual norms and the medicalization of
sexual problems into notions of health, illness, and normalcy—that is, clas-
sification into dysfunctions and disorders. According to Riesmann (1983: 4)
The term medicalization refers to two interrelated processes. First, certain

behaviors or conditions are given medical meaning—that is, defined in
term of health and illness. Second, medical practice becomes a vehicle
for eliminating or controlling problematic experiences that are defined as
deviant.
(in Tiefer, 2004: 23)
This perspective is reiterated in Leonore Tiefer and her colleagues’ “campaign”

known as “A New View of Women’s Sexual Problems” (Kaschak and Tiefer,
2001) and a “New View of Men’s Sexual Problems” (Tiefer, 2006a).
In the United States sexual problems are discussed in a variety of arenas
from popular culture to the clinical sector. Because identifying the sources
of sexual problems spans biological, psychological, and socio-cultural perspec-
tives, research reflects this rich array of interests. Research on this subject
involves the medical professions, including urologists, gynecologists, and en-
docrinologists and psychiatrists, the mental health sectors, such as psychol-
ogists, mental health professionals, and therapists, and social scientists from
many disciplines. Since sexology and concerns over sexual well-being are such
a heterogeneous field with an extensive literature, we shall focus a critical eye
on the perspective taken in the American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders (DSM). This publication offers a
US/industrialized classification of sexual dysfunctions. Since the 1970s and
escalating in the following thirty-five years, trends showed an increase in med-
icalization of sexual dysfunctions. This has been occurring domestically and
internationally and is associated with expansion of pharmaceuticals and cap-
italism generally. The nosology (classification of disease) of sexual dysfunction
has changed over time and is reflected in various versions of the DSM. The
most current version is the DSM-V-TR (revised in 2013). Currently DSM-V-TR
sexual dysfunctions include:
• Delayed ejaculation
• Erectile disorder
• Female orgasmic disorder
• Female sexual interest/arousal disorder
302 Adult Sexuality
• Genito-pelvic pain/penetration disorder
• Male hypoactive sexual desire disorder
• Other specified sexual dysfunction
• Unspecified sexual dysfunction
Female arousal disorder was removed from the DSM-V because it is most often
identified in the context of hypoestrogenism, disqualifying it from a psychi-
atric diagnosis. The DSM-V is no longer premised on the assumption that
the human response cycle is primarily the same across the genders as it has
been in previous editions (Tiefer, 2004). Instead, diagnostic criteria is based on
the duration and severity of associated symptoms; dysfunctions are specified as
lifelong, or generalized in regard to duration. Severity is ranked as mild, mod-
erate, or severe and refers to the degree of distress over symptoms (McCabe
et al., 2016: 137). The DSM-V-TR classification affirms a perspective that sex-
ual dysfunctions are largely psychogenic in origin, although sexual disorders
are embodied in very real physiological problems in sexual functioning. Sexual
dysfunctions in the DSM-V-TR also include those caused by general medical
conditions such as male hypoactive sexual desire disorder; male erectile dis-
order; other female or male sexual dysfunction; and substance-induced sexual
problems in functioning.
According to some studies, diverse sexual problems are widespread in
the United States. Laumann, Paik, and Rosen (1999) using the National
Health and Social Life Survey has found figures as high as 40 percent of
women and 30 percent of men surveyed recounted problems with sexual
functioning. Selvin Burnett, and Platz suggest that 18.4 percent of the male
population in the United States over the age of twenty will be affected by
erectile dysfunction (2007: 152).The Florey Adelaide Male Ageing Study
(FAMAS) in Australia found that 31.7 percent of participants aged thir-
ty-five to eighty years old developed erectile dysfunction at the end of a
five-year period (Martin et al., 2017). While there are several large-scale
studies on male sexual disorders, equivalent research on women is lacking
(McCabe et al. 2016). One significant study of sexual experiences of Austra-
lian mid-life women found that 69 percent of participants experienced low
sexual desire and 40 percent experienced sexually-related distress (Worsley
et al., 2017: 680).
Disorders of Desire
The sexual disorders of desire include aversion and hypoactive forms that
affect both men and women, and are generally described as a disinterest in
sexual gratification. Aversion is defined in the DSM-V-TR as a “[p]ersistent
or recurrent extreme aversion to, and avoidance of, all (or almost all) genital
sexual contact with a sexual partner.” And hypoactive disorder is defined as
“Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fan-
tasies and desire for sexual activity,” (2013: 302.71 (F52.0)).
Adult Sexuality 303
Hyposexual desire disorder was first identified in 1970 (King, 2005). In the
1980s, Harold Lief, a therapist, suggested that hyposexual desire occurred in “20
percent of all adult Americans” (in Leo, 1984: 83). More recent research for males
by Laumann, Paik, and Rosen (1999) reports that 16 percent of men under sixty
reported low sexual desire; Rosen’s (2000) figures suggest a range of zero to 15
percent and Simons and Carey’s (2001) data suggest it is even lower in the zero-3
percent range. Meuleman and Van Lankveld (2005) regard hyposexual desire dis-
order as a particularly difficult problem to diagnose and treat in men, due to its
biological and psychological causes. However, a review of literature by Basson
(2005) found that as many as 30–35 percent of women ages eighteen to seventy
have had problems with sexual desire in the previous year. Research on difficulties
in desire has been attributed to biological influences such as low levels of testoster-
one in both men and women and to the role of dopamine. It must be pointed out,
however, that reports of treatments with testosterone and dopaminergic drugs im-
proved arousal and intensity of orgasm, but desire was not increased. In guidelines
issued by the Endocrine Society, Wierman et al. (2006: 17) note that
[a]lthough there is evidence for short-term efficacy of testosterone in selected

populations [of women], such as surgically menopausal women, we recom-
mend against the generalized use of testosterone by women because the indi-
cations are inadequate and evidence of safety in long-term studies is lacking.
Davis et al. (2005: 96) have concluded that “[t]he measurement of serum tes-
tosterone, free testosterone, or DHEAS in individuals presenting with low
sexual function is not informative and levels of these hormones should not
be used for the purpose of diagnosing androgen insufficiency.” In addition,
psychological factors alone or in combination with biological factors also in-
fluence both men and women’s desire. For example, depression and the use of
antidepressants can inhibit sexual desire, as can low self-esteem, anxiety, and
past negative experiences with sex (Bancroft, Loftus, and Long, 2003; Basson,
2005). Like other sexual problems, disorders of desire for both women and men
may increase with age. We shall discuss this aspect in Chapter 13.
In addition to aversion and hypoactive desire disorders, the media gave

a lot of attention to another desire disorder in the 1980s: “hypersexual”
response, known popularly as sexual addiction. This “problem” is not in-
cluded in the DSM, although it is included in the World Health Organi-
zation’s International Classification of Diseases (International Statistical
Classification 10, 2007; King, 2005). It has been estimated that as many
as 6 percent of U.S. people are hypersexual, using sex in the same way as
substance abusers. These individuals’ sexual behavior may place them at
risk for sexually transmitted infections. Whether hypersexuality is a sexual
disorder is debated by therapists and social scientists alike (Kor et al., 2013).
304 Adult Sexuality
Sociologists like Martin P. Levine and Richard Troiden (1988: 347–363)

warn that the creation of hypersexuality as a disease category will enable
the convergence of medicine and politics, two very powerful institutions,
in defining what is “normal” sexual behavior. Other mental health profes-
sionals believe that people with hypersexual disorder want and need help
with this serious psychological disorder (Karila et al., 2014). This nexus of
medicine and politics can be used not only to define what is normal, but
to control people through their sexuality, for example political efforts to
prevent gay and lesbian marriage/or unions.
Various theories have arisen specifically to address disorders of desire including

biological, psychological, and cultural explanations (we shall address sexual
dysfunctions more generally after discussing various discordances in the cur-
rent DSM-V-TR). Some sexologists attribute hyposexual desire disorder to fall-
out from the 1960s Sexual Revolution. Caplan and Tripp regard sexual taboos
as basic to sexual excitement, consequently as the last sexual taboos were bro-
ken during the 1960s and 1970s, so was the excitement associated with the for-
bidden lost (Lee, 1985: 83). Irvine (1990a) offers a socio-cultural analysis that
regards hyposexual desire as “the medicalization of a simple non-pathological
product of sexual boredom or indifference, due to the widespread problem of
flagging sexual interest in marriage” (in Davis, n.d.b: 13). Others have argued
for a more multidimensional view of sexual desire and of dysfunction (Ban-
croft, Loftus, and Long, 2003; Hicks, 2005; Kaschak and Tiefer, 2001; Tiefer,
2004, 2006a) that does not privilege biological explanations or imply norma-
tive cultural expectations in the evaluation and treatment of sexual problems.
In this regard, Basson (2005: 1327) has asserted:
Clinical and empirical studies, mainly of North American and European

adult women… have clarified sexual response cycles that are different
from the linear progression of discreet phases… Women describe overlap-
ping phases of sexual response in a variable sequence that blends the re-
sponses of mind and body. That women have many reasons for initiating
or agreeing to sex with their partners is an important finding. Women’s
sexual motivation is far more complex than simply the presence or ab-
sence of sexual desire (defined as thinking or fantasizing about sex and
yearning for sex between actual sexual encounters).
Arousal Disorders
In the DSM-V-TR female arousal disorder is defined as the
lack of, or significantly reduced, sexual interest/arousal, as manifested by

at least three of the following: Absent/reduced interest in sexual activity,
absent/reduced sexual/erotic thoughts or fantasies., no/reduced initiation
Adult Sexuality 305
of sexual activity, and typically unreceptive to a partner’s attempts to ini-
tiate, absent/reduced sexual excitement/pleasure during sexual activity in
almost all or all sexual encounters, absent/reduced sexual interest/arousal
in response to any internal or external sexual/erotic cues (e.g., written,
verbal, visual), or absent/reduced genital or nongenital sensations during
sexual activity in almost all or all sexual encounters.
(2013: 302.72 (F52.22))
Estimates in the United States population of female arousal disorder range

from 6 percent to 16 percent; with statistics increasing with age in women.
Laumann, the principle investigator in “The Global Study of Sexual Attitudes
and Behaviors Survey,” funded by Pfizer (the creators of sildenifil/Viagra), col-
lected data from 27,000 women and men aged forty to eighty from twenty-nine
countries. This research has identified an increasing incidence of men’s sexual
difficulties as they age including arousal problems. Problems with lubrication
are distinguished as the main age-related sexual issue for women who are not
more likely to have other age-related sexual dysfunctions. However, these find-
ings from “The Global Study of Sexual Attitudes and Behaviors Survey” are
problematic in that arousal disorders were defined using a strictly physiological
response without including the subjective element of the response; for exam-
ple, does the woman report feeling aroused (Bancroft, Loftus, and Long, 2003;
Basson, 2005). Current research is focused on including biopsychosocial eti-
ology in treatment regimes for female arousal disorder (Carvalho et al., 2013:
1550; Giraldi et al., 2013: 59; McCool-Meyers et al., 2018: 10).
Erectile disorder is defined as the
marked difficulty in obtaining an erection during sexual activity, main-

taining an erection until the completion of sexual activity or marked de-
crease in erectile rigidity experienced on almost all or all (approximately
75%–100%) occasions of sexual activity (in identified situational contexts
or, if generalized, in all contexts).
(302.72 (F52.21)(DSM-V-TR, 2013)
Prevalence of this disorder includes statistics that 2 percent of men under forty
experience frequent problems with erections (Prins et al., 2002). Approximately
5–20 percent of men have moderate erectile dysfunction (Kubin et al., 2003:
66). The term impotence has been widely used in popular culture to describe
a man’s inability to obtain an erection. The concept of male potency does not
have a counterpart in terminology for women and is an obvious example of
the dual and sexist symbolization of male sexuality (Richardson, 1988: 129).
Erectile problems can occur for a variety of reasons. Most men have at some
time experienced the inability to have an erection due to “excessive fatigue,
heavy drinking, and/or over anxiousness about sexual performance—all of
which are characteristically associated with masculine activities” (Richardson,
1988: 129). Some, but not a complete list of, additional factors identified as
306 Adult Sexuality
causing or contributing to erectile disorder include prescription medications
(especially those for high blood pressure); diseases like atherosclerosis and di-
abetes; damage to nerve fibers due to surgery or trauma; and low testosterone
levels (Joannides, 2004).
Before the advent of the “sexopharmaceutical revolution” in the 1990s, re-
search on men’s erectile problems emphasized psychogenic and socio-cultural
factors, although harbingers of medicalization had begun earlier in the 1970s
followed by an initial expansion in the 1980s as the fields of urology and
pharmacology carved out a treatment niche. Industrialized masculinity in the
late twentieth and early twenty-first centuries continued to emphasize a penis-
centered model of performance and orgasm. The loss or decline of erectile
and orgasmic functioning is a serious threat to masculine identity shaped by
an ideology of phallocentrism—the ideal of producing erections at will and as
well as having staying power or sexual stamina (Kilmartin, 2007). Performance
not pleasure is emphasized in this industrial ideal of masculinity. Medicaliza-
tion of erectile dysfunction emerged as a sociological theory to critique the use
of medicine to dictate phallocentric norms of the male sexuality (Rosen, 1996;
Tiefer, 1994).
A psycho-cultural perspective toward male erectile problems was developed
out of the convergence of men’s studies and various social scientific approaches.
Generally speaking, before 1970, young men’s erectile problems were attributed
to psychological causes (related to the stresses of masculinity and other contex-
tual factors), and erectile disorders in midlife and older men were considered
part of the aging process, not necessarily a disorder. After 1970, however a shift
in emphasis occurred and male dysfunction came to be socio-culturally defined
incrementally over the last thirty-five years as a biomedical phenomenon (Tiefer,
2006a). At one time Masters and Johnson stated that as much as 80 percent of
erectile disorders were due to psychological factors; currently it is estimated by
doctors that perhaps 80 percent have a physical basis (King, 2005).
Viagra was born (approved by the FDA) March 27, 1998. With its invention
and that of its cohorts, it has become a major player in the ideologies of “nor-
mative” masculine sexuality. Treatments for erectile disorders were revolution-
ized by Pfizer, the creators of sildenafil (Viagra), whose clinical studies found
sildenafil produced erections in 70 percent of a test population of men with
erectile problems (Ault, 1988: 1037; Handy, 1998: 54). Tiefer suggests Viagra’s
timely success was due to “cultural shifts in gender role spotlighting genital ap-
titude as proof of masculinity, a tale examined repeatedly in men’s studies over
the last quarter-century,” (2006: 279). Other additional treatments for erec-
tile dysfunction currently available include psychological therapy, hormone
replacement therapy, vacuum devices, urethral suppositories, penile injections,
vascular surgery, and penile implants (King, 2005; “Putting the Pill (for Men)
in Perspective,” 1998: 4; Tiefer, 2006). All testify to the lengths that men will
go in the quest for phallic performance and living up to an industrialized (and
sometimes nonindustrialized) ideal of masculinity. New oral medications for
increasing blood flow to the penis are on the horizon. In the “New View of
Adult Sexuality 307
Men’s Sexual Problems,” Tiefer (2006a) offer a multidimensional approach
to masculine sexual difficulties, one that underscores the integration of bio-
psychogenic and cultural variables, including context and the nature of the
partner relationship. Tiefer (2004: 233) asserts:
Erectile dysfunction, a condition in the man’s genitalia, has become the

only acknowledged focus of interest, focus of evaluation, and focus of treat-
ment. This represents a substantial narrowing from sex therapy—erasing
the partner, erasing subjective meaning, and ironically, perpetuating the
obsession with penile hardness, which many sex experts have argued is
itself a primary cause of sexual unhappiness.
Orgasmic Disorders
Orgasmic disorders include both female and male, as well as premature ejacu-
lation in men. Female Orgasmic Disorder is defined by the DSM-V-TR (2013:
302.73 (F52.31)) as the:
Presence of either of the following symptoms and experienced on almost

all or all (approximately 75%–100%) occasions of sexual activity (in iden-
tified situational contexts or, if generalized, in all contexts) for a minimum
duration of 6 months:
1 Marked delay in, marked infrequency of, or absence of orgasm.

2 Markedly reduced intensity of orgasmic sensations.
This disorder includes several variations. Primary orgasmic dysfunction is

associated with women who have never had an orgasm. Secondary orgas-
mic dysfunction occurs in women that have been orgasmic but are no lon-
ger. Situational orgasmic dysfunction occurs under certain contexts but
not others (DSM-IV-TR 2000, 1997–2006; King, 2005; Masters and Johnson,
1970). Graham (2010) suggest 10–42 percent of women have orgasmic prob-
lems depending on cultural and geographical factors. It has been estimated
that 10–15 percent of women have never experienced an orgasm (Althof and
Schreiner-Engle, 2000). Causes have been ascribed to biogenic factors. Low
levels of testosterone have also been debated as playing a role (Basson, 2005).
Kaplan and Owett (1993: 3–24) initially identified the “female androgen defi-
ciency syndrome” substantiating an earlier Waxenberg et al. study in 1959, as-
serting that the loss of androgens in women can lead to loss of sexual desire,
decrease in orgasms, and loss of orgasmic ability. Androgen deficiency syndrome
was found to occur among women who had undergone chemotherapy or oopho-
rectomies (removal of the ovaries), and testosterone replacement therapy was the
prescribed treatment. However, as our discussion of hyposexual desire disorders
noted, guidelines by the Endocrine Society (Wierman et al., 2006) have chal-
lenged the efficacy and safety of testosterone treatments (also Davis et al., 2005).
308 Adult Sexuality
With the invention of sildenafil (Viagra), the pharmaceutical search for
a female Viagra has been vigorous. However, women’s sexual response has
proven far too complicated to be “fixed” with a pink Viagra. FDA approval
for a women’s Viagra has not occurred although it is prescribed off label for
women (Tiefer, 2006a). Medicalized perspectives on women’s orgasmic prob-
lems neglect the importance of a variety of other factors including sexual
knowledge, the relationship with the partner, personal history, stress, emo-
tional well-being, etc.
Delayed ejaculation disorder is defined as the marked delay in ejaculation
and infrequency or absence of ejaculation experienced on almost all or all oc-
casions (approximately 75%–100%) of partnered sexual activity (in identified
situational contexts or, if generalized, in all contexts), and without the individ-
ual desiring delay, (DSM-V-TR, 2013: 302.74 (F52.32)).
Prevalence rates are recorded as low as 1–3 percent to as high as 7–9 percent
of men (Laumann, Paik, and Rosen, 1999; Simons and Cary, 2001). Research
suggests that this problem is primarily of psychocultural origin associated with
the pressure for performance.
Another orgasm disorder for men is premature ejaculation. This is defined
in the DSM-V-TR as
persistent or recurrent pattern of ejaculation occurring during partnered

sexual activity within approximately 1 minute following vaginal pen-
etration and before the individual wishes it. Although the diagnosis of
premature (early) ejaculation may be applied to individuals engaged in
non-vaginal sexual activities, specific duration criteria have not been es-
tablished for these activities.
(302.75 (F52.4))
The clinician must take into account factors that affect duration of the ex-
citement phase, such as age, novelty of the sexual partner or situation, and
recent frequency of sexual activity. Premature ejaculation is a problem of con-
trol and is the most prevalent sexual dysfunction reported for men up until age
fifty-nine. It may be due to biological factors, but this is rarer; it is more likely
related to performance anxiety and other psychocultural factors. Debates as to
rates of occurrence include figures from 20 percent to 30 percent of men expe-
riencing premature ejaculation, with disagreement on how it is defined (King,
2005; Saitz, 2016; Serefoglu and Saitz, 2012).
Sexual Pain Disorder

Sexual pain disorder includes dyspareunia for both men and women and
vaginismus for women. Dyspareunia is defined as “[r]ecurrent or persistent
genital pain associated with sexual intercourse in either a male or a female,
before during and after intercourse” (DSM-IV-TR, 1999–2006). For women,
the DSM-V recently combined dyspareunia and vaginismus under one single
Adult Sexuality 309
category of genito-pelvic pain/penetration disorder. One census study ascer-
tained that 7–8 percent of women could experience chronic burning vulvar
pain (known as vulvodynia) lasting longer than three months by the time they
were forty years of age (Harlow et al., 2014: 7). The overall incidence of women
eighteen to sixty-five who can’t have intercourse due to pain is 10 percent ac-
cording to Basson (2005) and Pukall et al. (2016) suggests that 10–28 percent
of women suffer from vulvodynia at some point in their lives. Vaginismus is
defined in the DSM-IV-TR as the
[r]ecurrent or persistent involuntary spasm of the musculature of the outer

third of the vagina that interferes with sexual intercourse, but it is also as-
sociated with unexplained recurrent or persistent involuntary contraction
of the perineal muscles around the outer third of the vagina associated
with penetration with any object.
(1997–2006)
The most recent edition of the DSM (DSM-V) does not indicate vaginismus as
its own disorder, but rather includes it in with dyspareunia under the category
of genito-pelvic pain/penetration disorder. Concerns about this change regard
the fear that vulvodynia, vulvar pain or a burning sensation with or without
penetration, will be misdiagnosed as a genito-pelvic penetration disorder and
will primarily be treated through psychological interventions (Vieira-Baptista
and Lima-Silva, 2016: 1). Etiology of what was previously known as vaginismus
is usually attributed to psychological and/or biological factors, but vulvodynia
can have a variety of causes. Treatments include psychotherapy, antidepres-
sants, topical and injected steroids, and estrogen, among other interventions
(National Vulvodynia Association (NVA) (Research Update Newsletter,
2005). The National Vulvodynia Association is a patient advocacy group dedi-
cated to improving the sexual lives of women who have vaginal pain.
Sexual Difficulties in Cultural Context

According to Goldberg (1985), our cultural conditioning undoubtedly creates
a situation in which “sex is at cross-purposes.” The gendering process of sex-
ual socialization creates mismatches between the genders. Men are socialized
through a recreational model of sexuality to experience sex as conquest with
the goal orientation of orgasm. Women are socialized in a relational model to
experience sex as intimacy and as a process of achieving closeness. Gender
role mismatches also occur. As the initiator, the male carries the entire re-
sponsibility for making sex fulfilling and, consequently may experience guilt
and resentment over this role. In tandem, the female, in her role as reactor,
may come to feel anger over being sexually controlled. Goldberg suggests other
cultural oppositions occur as a result of divergent gender role expectations in-
cluding cultural assumptions of male “promiscuity”/desire for multiple partners
countered by female desire for monogamy, and in the role dichotomy of male as
310 Adult Sexuality
animal—female as Madonna. In addition, the expression-repression mismatch
is one in which males learn to regard sex as a “preoccupation” and females see
“sex… [as]… something that may be enjoyed under special conditions of com-
mitment and intimacy but, at the same time, something a woman feels she can
do without if the circumstances are not right” (Goldberg, 1985: 147).
Although these trends may be exaggerated and not representative of the
heterogeneity nor of ethnic diversity in sexual attitudes of the twenty-first cen-
tury, there is still some truth to these as cultural ideals for many middle-class
Anglo Americans. Much sexual dysfunction is due to the anxiety, guilt, and
repression spawned by inequalities between the genders and the disparities
in gender status and role (i.e., gender stratification). Paradoxically, while the
Sexual Revolution and the new age of sex research may have tempered some of
these problems caused by gender status and role inequities, a host of new fears
associated with performance anxieties have arisen.
A critical constructionist perspective integrates not only the cultural con-
text in which sexual dysfunctions occur but the numerous ways in which the
medical and mental health sectors define, label, categorize, diagnose, and treat
sexual dysfunctions; for example, the terms for describing human sexuality
such as “dysfunction” and “dyspareunia” focus on difficulties and pain. Medical
terms emphasize a disease model and concentrate on the dysphoric aspects of
sex rather than the euphoric. The clinical approach to diagnostic categories
for sexual disorders has been critiqued as ethnocentric, classicist, and sexist by
an ample body of socio-cultural literature (Bancroft, Loftus, and Long, 2003;
Davis, n.d.: 1; Tiefer, 2004, 2006a, b).
Although the condition is all too real for the individual suffering from these
problems, this should not blind us to recognizing that there are cultural biases
in approaching sexual dysfunctions (Davis, n.d.: 1–28). For the disorders asso-
ciated with timing, such as too soon or perhaps too late, cultural beliefs shape
the tempo of sexual arousal and these can vary by gender, ethnic group, class,
and cross-culturally. For example, some heterosexual males may regard delayed
ejaculation as more of a problem than their partners do. A woman’s orgasm
difficulties may be related to a lack of understanding of sexual functioning,
beliefs that sex is dirty or bad, or that sex is immoral. Both men and women
may have sexual problems caused by the partner’s lack of knowledge and sex-
ual expertise.
A New View of Women’s and Men’s Sexual Problems

In 2003, Lenore Tiefer and a working group of colleagues launched a campaign
entitled A New View of Women’s Sexual Problems that offered an alternative
standpoint. This campaign took issue with the increasing medicalization of
women’s sexuality, such as the pharmaceutical quest for a female Viagra, the
encroachment of the medicalization of menopause, as well as the system of
classification of women’s sexual disorders in the DSM. This campaign resulted
in publications, conferences, and a website (FSD-Alert; Kaschak and Tiefer,
Adult Sexuality 311
2001). A New View of Women’s Sexual Problems regards the medical classifi-
cation scheme in the Diagnostic and Statistical Manual of Mental Disorders as
a “fundamental barrier to understanding women’s sexuality” (“Female Sexual
Dysfunction: A New Medical Myth,” 2006; “The Manifesto,” 2002). The DSM
was criticized on several grounds in A New View of Women’s Sexual Problems.
• It assumes there is a universal, normal sexual response (i.e., drive).

• It defines human sexuality response primarily in terms of physiological
function.
• It assumes that human sexual response occurs in a linear cycle.
• It ignores the differences among women.
• It disregards the importance of the relationship in sexual functioning.
• It assumes that women and men are alike by disregarding the socio-cul-
tural parameters of sexuality (Hicks, 2005; Tiefer, 2004).
A burgeoning body of research supports this critique and perspective. Com-

pelling evidence attests that women’s sexual responses do not follow the linear
DSM model, but are rather “overlapping” and heterogeneous, blending mind
and body, influenced by socio-cultural context and relationship satisfaction in
a bio-psycho-social matrix (Bancroft, Loftus, and Long, 2003; Basson, 2005:
1327; Mah and Binik, 2005).
In 2006, “The ‘New View’ Approach to Men’s Sexual Problems” created
by Lenore Tiefer (2006a) reflected similar concerns regarding men’s sexual
problems; that is, men’s sexuality is reduced to erections, with a similar cri-
tique of the DSM resulting in a “New View Classification of Sexual Problems
(Affecting both Women and Men)” (Tiefer, 2006a: 12). “A New View of Sex-
ual Problems” self-consciously uses the terminology sexual “problems,” not sex-
ual “dysfunctions” or “disorders” and denies that there is linear sexual response
cycle. It argues that women and men “may be dissatisfied with any emotional,
physical, or relational aspects of the sexual experience” (Tiefer, 2006a: 12).
The causes of this dissatisfaction may range from social, relational, personal,
or physical. These four aspects are interrelated dimensions of people’s sex lives
and are presented in order of “likely prevalence” and in order of suggested in-
terventions as well. These are identified as:
• Sexual problems due to socio-cultural, political, or economic factors.

• Sexual problems due to partner and relationship.
• Sexual problems due to psychological factors.
• Sexual problems due to physiological or medical factors (Tiefer, 2006a:
12–13. For a detailed view see “The ‘New View’ Approach to Men’s Sexual
Problems”).
The causes of sexual dysfunction may be analyzed from the societal/cultural

level to that of the individual. When discussing the psychosomatic aspects of
sexual dysfunction that are associated with anxiety, the cultural perspective
312 Adult Sexuality
must be included so that the effects of cultural patterning may be considered.
In addition, there are physiological factors that can affect sexual functioning
including disease (e.g., cancer, bladder disorders, diabetes, structural damage)
and response to drugs (e.g., diuretics, adrenal steroids) (Kaplan, 1979). Davis
(n.d.: 1–35) has reviewed and critiqued the Sexual Disorders in the Diagnostic
and Statistical Manual of Mental Disorders IV, and has proposed that in order to
maintain and understand the role of culture in shaping diagnosis in our indus-
trialized society, we need to move beyond “categorizing and classifying sexual
behavior to an emphasis on questioning and analyzing the constructions of
the categories themselves, as culture-bound” (Davis, n.d.: 11). In 2013, The
DSM V merged several sexual disorders together under the title “female sexual
interest/arousal disorder” and made several changes to the categorization of
male sexual disorders (IsHak and Tobia, 2013: 1). Campbell et al. (2015: 436)
conceptualize sexual disorders in the DSM-V in frameworks that look beyond
scientific classifications and discuss socio-cultural factors that implicate certain
clinical beliefs and definitions of sexual disorder. This is particularly important
in seeking to understand sexual dysfunction in other ethnic groups or cultures
because the industrialized clinical theories of sexual dysfunction ignore the
role of culture and ethnicity. This perspective combined with “A ‘New View’
of Sexual Problems” provides a template for understanding the complexities in
human sexual response as biological, psychological, and cultural phenomenon.
Hookup Culture
In line with the approach to human sexuality in this book, Garcia et al. (2012)
note that the phenomenon of modern hookup culture “provides a case of hu-
man social behavior through which to explore the relationship and possible
interaction between evolved mating psychology and cultural context “(162)
and that it is “best understood from a biopsychosocial perspective that in-
corporates recent research trends in human biology, reproductive and mental
health, and sexuality studies” (172). As “hooking up” has evidently become the
dominant and normative sexual script for men and women in the twenty-first
century, its ubiquity both reinforces and challenges many traditional ideas
about gender and sexuality (Bogle, 2008). “Hooking up—brief uncommitted
sexual encounters among individuals who are not romantic partners or dating
each other—has taken root within the sociocultural milieu of adolescents,
emerging adults, and men and women throughout the Western world” (Garcia
et al., 2012: 161).
How does “hooking up” differ from other forms of casual, non-committal
sex? This question has been perhaps the most challenging for scholars to define
because its very ambiguity is what apparently makes it preferable to saying that
two people “had sex.” Hooking up can include any behaviors that participants
construct as intimate or sexual in nature. From kissing to intercourse, hook-
ing up can refer to any sexual activity or behavior that can be interpreted as
such in specific situational or cultural contexts. However, hooking up has not
Adult Sexuality 313
necessarily replaced, nor is it necessarily incompatible with human desires for
committed long-term relationships, pair bonding, or classic notions of finding
romance (Fielder, Carey, and Carey, 2013). In fact, successful relationships can
evolve from casual hookups. On the other hand, especially for adolescents and
young adults, hookups often involve alcohol or drug consumption and in some
cases lead to sexual coercion and unwanted sexual encounters. Sexual consent
in particular has emerged as a contentious issue scholars have struggled with in
deciding whether or not hookup culture is liberating or oppressive, especially
for young college-aged women (Muehlenhard et al., 2016).
In American Hook Up: The New Culture of Sex on Campus (2017) Lisa Wade
provides a deeply insightful sociological case study of why hookup culture goes
far beyond college students having casual sex. Whereas students have consis-
tently taken advantage of sexual permissiveness or exploration during their
college years, hookup culture is a novel phenomenon. Hookup culture, Wade
argues, permeates and is supported by various social organizational norms as
well as institutional structures of colleges past and present. Hookup culture
is deeply embedded in campus life and Greek organizations in particular.
Students, especially freshmen cohorts, become absorbed in what she describes
as a “fog” which initially disorients them but inevitably re-orients them to
conform to the social pressures to hook up. Greek organization membership,
fraternity parties, alcohol consumption, and strong peer pressure to raise one’s
social status via the number and status rank of sexual partners are key factors
in why hookup culture thrives in four-year residential colleges. Students who
do not or cannot conform to what is essentially a white, male, heterosexual
party culture environment are systematically excluded. In a sense, students’
sexual status that depends on participation in hookup culture determines stu-
dent’s social status on campus. This applies more or less to both female and
male students.
How did hookup culture become such an all-encompassing, dominating culture
on residential college campuses nationwide? Wade traces modern hookup culture
back to nearly a century ago when unprecedented numbers of young people were
able to attend college. Being on their own, away from parental supervision, and
able to organize social life around mixed company, fraternity men clashed with
administrative officials who tried to cultivate the college experience as a serious,
dedicated pursuit of education devoid of leisure and pleasure. However, fraternities
gradually succeeded in framing college and campus life as a period of carefree in-
dulgence and independence. By the 1960s, women, too, had begun to rebel against
retaining sexual purity and aspiring to normative monogamous marriage ideals.
Female college students flocked to fraternity parties designed to create a sexually
permissive atmosphere controlled by men, characterized by the transactional na-
ture of providing entertainment and alcohol in exchange for implicit sexual com-
pliance. This kind of formulaic social interaction persists to this day across many
residential campuses with strong Greek affiliations.
Wade shares the claim of many other scholars who argue that hookup cul-
ture reproduces rigid, heteronormative gender norms and sexual scripts that
314 Adult Sexuality
devalue and harm women while reinforcing men’s sexual dominance and
sexual privilege. And although many college women willingly participate in
hookup culture as they see casual sex as liberating them from oppressive so-
cial expectations of commitment and monogamy, most experience at least one
non-consensual, coerced, or forced sexual encounter. In fact, sexual consent
becomes a highly contentious issue in situational contexts designed precisely
to obscure or negate its necessity.
But do college students who participate in hookup culture really enjoy and
thus have more sex than those who opt out? Wade’s findings show that a quar-
ter of students who participate seemed to enjoy their carefree casual sexual
encounters, while one third opted out entirely, and the rest “dabbled” in it but
felt ambiguous about it. The most interesting finding Wade reveals, however, is
that in general, even those most deeply entrenched in hookup culture do not
have as much sex as we would expect: on average, graduating seniors in her
sample hooked up about eight times in four years, and many not at all. None-
theless, she maintains that even if students opt out of hooking up, they cannot
escape becoming absorbed in hookup culture.
Wade repeatedly cautions readers not to problematize casual sex among col-
lege students, but rather to be mindful of hookup culture’s compulsory nature
and its negative consequences such as social exclusion, sexual exploitation,
and maintaining gender hierarchies that clearly privilege the social status and
sexual needs of men. The barriers to changing the negative aspects of hookup
culture, Wade suggests, need be addressed by focusing on structural, institu-
tional changes that begin with buffering powerful fraternity organizations who
singlehandedly shape the social life on campus, and must include alternative
social and sexual opportunities not based the dominance of white, male, het-
erosexual privilege.
There are numerous other problematic aspects and social variables asso-
ciated with hookup culture’s contentious stronghold within and beyond the
college context. Vrangalova (2015) notes that the problem of defining what
exactly constitutes a hookup makes cross-study comparisons rather compli-
cated. Emotional connections, intimacy, and seeking long-term romantic rela-
tionships are seen as so antithetical to college hookup culture, that individuals
who express these more traditional values are punitively excluded from it. At-
tachment styles and motives of sexually active college student populations also
inform hookup decision-making and satisfaction outcomes (Snapp et al., 2014).
Helm et al. (2015) found that religious backgrounds or religious involvement of
college students lessens participation in the sexual permissiveness of hookup
culture by about 40 percent. Although both men and women seek out casual,
non-committal sexual hookups, women tend to be more emotionally motivated
to engage in hookups, and are more affected by male non-investment than
men (Townsend and Wasserman, 2011). Race, ethnicity, and socio-economic
markers similarly shape student population involvements in hookup culture in
that non-white, immigrant, or low-income students tend to be less involved
or de facto excluded (Allison and Risman, 2014; Brimeyer and Smith, 2012).
Adult Sexuality 315
Residential proximity, compared to two-year community or commuter col-
leges, also sets the stage for hookup culture to emerge (Wade, 2017).
Sex and Social Media

Web based dating sites and mobile dating apps have profoundly transformed
how humans find sexual partners, casual dates, long-term relationships, and
marriage partners. While “mail-order brides” are a rather shady phenome-
non that existed way before the Internet, access to a global array of potential
partners is a product of our increasingly digital lives. “As online dating be-
comes more common,” write Ranzini and Lutz, “the associated level of neg-
ative stigma seems to shrink.” (2017: 81). Dating apps can be thought of as
“intermediaries through which individuals engage in strategic performances
in pursuit of love, sex, and intimacy” (Hobbs, Owen, and Gerber, 2017: 271).
And although mobile dating app use is increasingly common among all age
groups with diverse social characteristics, personality traits such as trust to-
ward people online and sensation seeking appear to be central to using them
(Chan, 2017). Among teenagers and college students, mobile communication
has not only become central to hookup culture, but also to the very definition
of their sexual identities, expectations, and behavioral norms (Goluboff, 2016).
However, the popularity of dating apps and its widespread use in connection
to hookup culture also reveals an increased risk of unprotected sex with casual
sexual partners among its users (Choi et al., 2016).
Tinder in particular has drawn the attention of scholars to the enduring
cultural phenomenon of mobile app use as a primary means of finding casual
sexual partners. At the time of writing, millions of people all over the world
use Tinder, and over 1 billion swipes were recorded as early as 2014 (“Tinder
Revenue and Usage Statistics,” 2019). Duguay (2017) has investigated Tinder’s
ability to assuage concerns about authenticity claims of Tinder users that
speak to the “normalization” of dating in the mobile age. David and Cambre
(2016) discussed how Tinder transforms user’s notions of intimacy by gamify-
ing and simplifying mobile interactions on screens, and Heino, Ellison, and
Gibbs (2010) refer to the swiping phenomenon as “relationshopping.” Ran-
zini and Lutz (2017) found gender differences in impression management that
inform truthful or deceptive self-presentation, and Strubel and Petrie (2017)
have shown how Tinder affects body consciousness and internalization of
beauty ideals.
Gay and lesbian dating apps follow a similar interactive architecture but
differ in ways that condition the matches or shape the encounters. For ex-
ample, Grindr, a gay men’s dating app, does not require a Facebook account
and link to establish basic authentication verification. Before the Internet and
before mobile phone use of location specifics, gay men and lesbian women
made covert use of “known” public spaces to find sexual or romantic part-
ners. Gay men’s casual sexual encounters in public spaces have always followed
specific interactional codes such as gazes and gestures while lesbian women
316 Adult Sexuality
carved out meeting spaces shaped by the assumption of shared sexual identi-
ties and desires. Dating apps, however, changed the often non-communicative
scripts of simply “being in the know”; popular gay and lesbian dating apps
such as Grindr and Her require at least a minimal, if scripted communica-
tion exchange before casual sexual encounters take place (Licoppe, Riviere,
and Morel, 2016). However, location awareness or “location based real time
dating” as Blackwell, Birnholtz, and Abbot note, is the key feature that turns
any geographic location into a space where men find each other for casual sex
(2015). As one of their research participants remarked, Grindr “gives me the
chance to pull out my phone and have a gay bar in my pocket” (1126). Les-
bian dating apps, initially created as “reskins” (recycled interfaces of gay men’s
dating apps), have been criticized by lesbian communities for its ideological
mirroring of gay male identities, desires, and behaviors in mobile apps that
focus mostly on immediacy and proximity rather than on community building
and communication (Murray and Ankerson, 2016). Nonetheless, mobile apps
feature prominently in how people of all ages navigate the modern world of
sex, dating, intimacy, and love.
Parenting Styles
Regardless of group structure and sexual orientation, the socialization of chil-
dren is an ongoing concern in all societies. Parenting within mainstream US
culture is undergoing rapid behavioral and attitudinal changes. The average
marriage in this culture lasts seven years, comparable to medieval Western
European marriages. However, our marriages usually end through separation
or divorce in contrast to the death of a spouse as occurred in medieval times
(Stone, 1977). At the same time, American longevity continues to increase,
with an average life expectancy of about seventy-six years for a middle-class
white male and about eighty-one years for a middle-class white female (World
Bank, 2017). In addition, nuclear family size is decreasing largely due to eco-
nomic and subsistence reasons—it’s expensive to raise children to adulthood
in a highly technical, post-industrial society. The demography of parenting is
also shifting. At one end are young (under fifteen years old) female teenaged
parents who encounter socio-economic problems since teenagers are not rec-
ognized as legal, social, or economic adults. At the other end are “older” adult
parents, women older than thirty-five experiencing their first pregnancy. The
overall average age of first pregnancy in this culture is about twenty-four years
(US Census Bureau, 2000).
The ideal post-WWII nuclear family is the least common family structure;
approximately 23 percent of households are headed by single parents. Although
over one million men are full-time single parents, the majority of single parents
are women, either by circumstance—divorce, separation, or desertion—or by
choice (US Census Bureau, 2016).
Currently, in two-parent households, generally both parents work outside
the home full-time. This creates a need for childcare—largely in the form of
Adult Sexuality 317
paid, nonkin-based arrangements such as daycare centers based on class, not
ethnicity. In-home division of labor and time spent parenting are highly vari-
able in these situations. Frequently, the presence of a child restructures the
adult relationship along more “traditional” lines, where the female assumes
primary responsibility for housework and childcare responsibilities in addition
to full-time paid involvement. Although fathers are emotionally and socially
bonded to their children, their in-home responsibilities usually are not equally
shared with their female partners (Hochschild, 1989). Hochschild’s research
(The Second Shift) indicates that women in two-income families work an
equivalent of an extra month a year with their additional household respon-
sibilities (1989).
Parenting and gender role options are becoming more flexible as indicated
by the greater availability of assisted reproductive technology (ART) (see
Chapters 6 and 7), more educational and career opportunities for women,
a rise in divorce rates, and greater numbers of single heads-of-households
(AAUW, 1989: 5; US Bureau of Labor, 1985; US Census Bureau, 2000). With
increased tolerance and visibility of alternative lifestyles, more gays and les-
bians are more openly involved in parenting. Although increasing numbers
of gays or lesbians are adopting children or having their own through ART,
it is still difficult for them to obtain custody or reasonable visiting rights of
children from their marriages (Boston Women’s Health Collective, 1976, 1984,
1992, 2005; Douglas, 1990; Whelehan, 1987). However, a few legal decisions
have allowed gay and lesbian parents to maintain contact with their minor
children. In Virginia, a lesbian mother was awarded custody (Morning Edition:
Lesbian Mother in Custody, 1994; SOLGAN, 1992; “The Courts Are Again
Asked to Redefine Families,” 1990). Lesbians also have the legal option of
AI-D, which is available to them through clinics in urban areas or more infor-
mally through arrangements made with male friends. Lesbians stand a greater
chance of parenting their biological children than do gays. For gays to do so,
they must either “pass” in a heterosexual marriage, hope to receive visitation
rights if they divorce, or find a woman willing to bear their child and let them
raise the child. This latter option, known as surrogate mothering, is a difficult
situation for gays or straights, married, or single men. Genetic parenthood is
more preferred by gay men, however it’s an expensive process and states that
are particularly lacking in LGBT-friendly reproductive clinics leave gay men
with a limited surrogacy market (Jacobson, 2018: 19). While there is significant
ethnographic research regarding gay men’s parenthood through gestational
surrogacy (Bergman et al., 2010; Blake et al., 2017; Dempsey, 2013; Smietana,
2019), male perspectives of infertility are particularly lacking in national data
(Culley et al., 2013; Jacobson, 2018: 19).
From research conducted in the 1970s (e.g., Green, 1978, 1979a, b), children
of homosexual parents are as likely to be homosexual as are children of het-
erosexual parents. More recent research, which surely needs more follow-up,
suggests possibly a familial tendency toward male homosexuality (Bailey and
Pillard, 1991; Hamer and Copeland, 1994). Lesbians do not create man-hating
318 Adult Sexuality
daughters and sexually confused sons any more than gays create misogynist sons
and sexually confused daughters. One gay man says of his daughter and son,
“They’re so normal,” a statement many of us who are parents would like to make
about our children. His children are proud and accepting of who their father is.
Their conflicts, shared closeness, and confidences are what many parents in the
United States hope to achieve with their children (Whelehan’s files).
Single-parent households, which are primarily headed by women, frequently
function under severe economic restrictions unless the woman is a middle-class
career person who chose single parenting (Crooks and Baur, 1987; Hochschild,
1989). In female-headed single-parent households, there are a variety of par-
ent-child interactions and male role models available to the children in the
form of extended kin relations such as the mother’s brothers or the mother’s
father, non-sexual male friends, and sexual partners (Dugan, 1988). This is a
well-established, adaptive pattern in many lower income African American
and Latino households (Dugan, 1988; Stack, 1974).
In single-parent, male-headed households, the economic situation is usually
more stable, more secure, and more comfortable (AAUW, 1989: 5). Men earn
approximately 28–34 percent more than women in comparable positions, and
after divorce experience about a 43 percent increase in disposable, or available,
income; however, women often experience a drop in disposable income of al-
most 33 percent (Boston Women’s Health Collective, 2005; Faludi, 1991: 22).4
It is also more socially acceptable for a male as a single person and parent in
US society to seek a relationship with a woman than for a female single parent
to seek a relationship with a man. As with women, men rely on paid childcare,
extended kin, and non-sexual friends of both genders for support and to be
female role models for their children. Use of extended kin and non-kin as a
means of socioeconomic support and socialization of children is a continu-
ation of our hominid behavior of alloparenting, where non-human primate
“sisters” and “aunts” care for the young as well as the biological parents.
Since a significant proportion (23 percent) of families in the United States
comprise single-parent households, this involves qualitative shifts in parenting
and childcare similar to those mentioned for dual-income families (US Cen-
sus Bureau, 2019). In nonindustrialized societies and for some ethnic groups in
industrialized societies, childcare can be managed within extended kin and
clan relationships. For the middle class in the United States, extended kin re-
lationships have been attenuated since the beginning of the twentieth century.
Increasingly, middle-class parents, both single and dual, turn to paid, non-kin–
based childcare, professional childcare “experts”—counselors, educators, pedia-
tricians, how-to advisors—and literature for information, support, and help in
raising children. Blue-collar and lower-class kin groups tend to tie into social
service agencies and extended kin for help in childrearing (Rubin, 1975).
In the southern United States, there is the practice of courtesy aunts/

uncles for parenting children not related by blood or marriage.
Adult Sexuality 319
The present generation of children is also the first generation as a group to
be raised in either single-parent or blended families (i.e., stepparent house-
holds) on a large-scale basis. They grew up as children in kin groups, which
lived through and with the Sexual Revolution, changed gender roles, sexual
behaviors, and divorce. It will be interesting to observe what decisions these
children make as adults about finances and careers, marriage, childbearing
and -rearing, and relationships.
Teenaged Parents
A parenting situation defined in this culture as highly problematic is teen-
aged parenting, particularly for those teens younger than fifteen. We (in the
United States) have the highest rate of teenaged pregnancy of any industri-
alized society (The Alan Guttmacher Institute; Wattleton, 1990; World Health
Statistics Annual, 1988). Approximately 18.8 babies are born per 1,000 teenage
women aged fifteen to nineteen years old in the United States (Martin et al.,
2017: 1). Yet, teenagers in the United States are not culturally recognized
adults physically, socio-psychologically, economically, legally, or politically.
Most of these teenagers give birth to their children and many decide to keep
and raise them. It is a cultural situation of “children having children.” These
teenagers have a high rate of complications during pregnancy and child-
birth including premature births, low birth-weight babies, or spontaneous
abortions. Often, the fathers of the babies, many of whom are men in their
twenties, not teens, cannot and do not economically and socially support the
nuclear families they have created (Males, 1992: 525). There was a decrease
in the overall number of teenaged pregnancies during the 1990s with both
sides of the sex education controversy claiming success for this decline (The
Alan Guttmacher Institute). This trend has continued through the twen-
ty-first century.
Younger teenaged parents often become dependent on the social service sys-
tem, which varies greatly by state relative to how much economic, social, and
emotional support is available. These teens can have a difficult time gaining
the culturally appropriate skills such as job training, high school, or college
education. Survival mechanisms include support from extended kin networks,
particularly in economically poorer, white, African American, and Latino
families, and reliance on Aid for Families with Dependent Children, referred
to as TANF (Temporary Assistance to Needy Families). Larger societal in-
stitutions perceive teenaged pregnancy and parenting as an unresolved crisis
situation (The Alan Guttmacher Institute; Wattleton, 1990).
Summary
1 Sex is defined as a biological, psychological, and cultural phenomenon
with attention to the importance of culture in shaping its meaning and
expression.
320 Adult Sexuality
2 Cross-cultural evidence was introduced including Mangaian and Tantric
models of sexuality; these were contrasted with industrialized models.
3 Industrialized models of sexuality were introduced in a critical and histor-
ical framework.
4 Prominent researchers of sexology were discussed including Freud, Kinsey,
Masters and Johnson, Kaplan, Singer and Singer, Whipple and Perry, Lau-
mann and colleagues, and Tiefer and colleagues.
5 Problems in sexual response were addressed including sexual dysfunction
and sex therapy. These were placed in a biological, psychological, and
cultural framework.
6 The clinical perspective of sexual dysfunction is compared to the “New
View of Women’s and Men’s Sexual Problems.”
7 Hookup culture and social media have significantly reshaped modern dat-
ing culture.
8 Parenting styles vary, and blended families and teenage parents are be-
coming more frequent.
1 How do college students define “hooking up”? Describe how sexuality is
negotiated by women and men in the encounter. What expectations do
you think are involved?
2 What is your response to the “New View of Women’s and Men’s Sexual
Problems”?
Suggested Resources
Books
Gagnon, John H. 2004. An Interpretation of Desire: Essays in the Study of Sexuality.
Chicago, IL: University of Chicago Press.
Tiefer, Leonore. 2004. Sex Is Not a Natural Act. Boulder, CO: Westview Press.
Article
Noonan, Raymond J. 2001. “Web Resources for Sex Researchers: The State of the Art,
Now and in the Future.” The Journal of Sex Research, 38(4): 348–351.
Websites
The Kinsey Institute for Sex, Gender, and Reproduction. See sections: Research
Program, Current Research Projects, Research Publications, Selections from the
“Kinsey Reports” 1948–1953 and Kinsey Institute Data and Codebooks. http://www.
kinseyinstitute.org/research/surveylinks.html. Last accessed 12/12/06.
Shiva Shakti Mandalam. This Is a Comprehensive Tantric Resource Site on the Inter-
net. http://www.religiousworlds.com/mandalam/index.html. Last accessed 12/12/06.
Stages, Part IV
Sexuality and Aging
Chapter Overview
1 Introduces biological, psychological, and social factors of sexuality and
aging.
2 Discusses aging men and andropause in the United States.
3 Discusses aging women and menopause in the United States.
4 Examines hormone replacement therapy (HRT/MHT) to address menopause.
5 Discusses sexuality during women’s menopause years.
6 Explores cultural ideologies of aging and sexuality in cross-cultural
contexts.
Sexuality and Aging

As we age (which is a “normal” physiological process for all animal species),
our physical and socio-psychological expressions of sexuality change as well.
Although there are issues in how aging and sexuality are defined and concep-
tualized, we will emphasize the process of aging and the research on sexuality
in older populations. Ideas and definitions of what constitutes “older” vary
with the particular study under consideration.
Through the aging process certain physiological changes occur that will
affect how people express and experience their sexuality. But we must bear in
mind that the aging process of sexuality is as much shaped by cultural norms,
values, and expectations including concepts of personhood and the body as it
is by the physiology of the aging process. In addition, class, status, ethnicity,
and gender are all intervening variables that may intersect with health and ill-
ness during aging. Cultural features intervene in the biological process of aging
and influence how humans experience their sexuality through the life course.
Unfortunately, there are a number of methodological issues in studying the
aging process, particularly as it applies to the elderly. One problem is in defin-
ing what we mean by a particular point/age in the life cycle. Is fifty “middle
age?” What age groups constitute middle age? How do we define elderly and
old age? We know that aging is a biological, psychological, and cultural process
that is related to cultural expectations about the life cycle and beliefs about
aging. In the United States “elderly” is usually (but not invariably defined)
322 Sexuality and Aging
age sixty-five or older and mandated by government issues of subsidy and re-
tirement. Not only do studies of aging and sexuality differ regarding at what
age elderly starts, this also varies cross-culturally. For Kinsey and colleagues,
old age started at sixty; however, from an emic perspective, some would vehe-
mently disagree that sixty is “elderly.” The Euro-American and industrial view
of aging and the life course uses a temporal/age-based model that reflects the
US concerns with time, the future, newness, and youth (Clark and Anderson,
1975: 335; Robbins, 2006).
Other problems that occur in framing the study of aging, sex, and elders is
that cross-culturally it may be difficult to ascertain exact chronological age. For
example, a consultant (collaborator, informant) may not actually know her/his
chronological age; furthermore adulthood, including US definitions of middle
age and old age, may be culturally codified in ways other than chronological
(Lamb, 2005). The cross-cultural record illustrates the diverse ways that the life
cycle may be segmented. Messenger notes that on the Irish island of Inis Beag,
“a man is a ‘boy’ or ‘lad’ until forty, an adult until sixty, middle-aged until eighty,
and aged after that…” (1971: 33). According to Marshall, for Mangaians, aging is
not experienced as a distinct phase but as continuation (1971: 145).
Even our scholarly approach to life stages such as childhood, adolescence,
adulthood, middle age, and maturity is a culture-specific one as we have dis-
cussed earlier. Brandes (1987) argues that our industrial concepts of lifespan
stages are permeated by our Euro-American cultural assumptions and notions
of age. For example, the age of forty in the United States is regarded as a major
transitional phase often associated with midlife crises, which the media has
helped to perpetuate (Brandes, 1987). In contrast, the Kgatla (Botswana) life
cycle for women has its own context-specific definitions. Menopause, which
marks the loss of reproductive ability, is regarded as a period in which a woman
is at the height of her knowledge and competence, continuing her role as a
mother, caretaker of home and family, and worker. However, menopause brings
with it the first signs of the beginnings of Kgatla old age. In contrast to indus-
trial societies, old age is not defined chronologically. Rather old age, “mosadi
mogolo,” is defined by increasing infirmity and the inability to work or manage
a household, not necessarily by age. It is associated with increasing depen-
dence and marks a loss of status as a result (Suggs, 1993).
Issues in the definition of sexuality in the aging process are problematic as
well. As elaborated in Chapter 12, how one defines and “counts” what sexual
activity is may differ throughout the life course (Lancaster, 2003; Tiefer, 2004).
If one defines sex primarily by heteronormative standards of penile-vaginal
intercourse, then a range of sexual behaviors, needs and desires are excluded
from analysis leading to a very narrow view of aging and sex over the life course
(DeLamater and Sill, 2005). This leads to an industrial model of sexuality that
eliminates the great variety of non-intercourse behaviors across the lifepsan in
what Riportella-Mueller (1989: 213) refer to as an all-or-none paradigm (also
Tiefer, 2004 among others). In addition, industrial/Euro-American research on
sex and aging has not only emphasized biological and medicalized definitions
of sexual “functioning” (defined as physiological responses: erection, lubrica-
tion), but are also based on data from US/industrialized societies (Kinsey et al.,
1948, 1953; Masters and Johnson, 1966), which may reflect cultural expecta-
tions about aging rather than physiological capability (DeLamater and Sill,
2005; Tiefer, 2004).
Kinsey et al. (1948, 1953) were among the first sex researchers to claim
that age made the biggest difference in human sexual response. Kinsey et al.
(1948, 1953) found lower levels of sexual activity after sixty, but later studies
by Masters, Johnson, and Kolodny (1985) and Cross (1993) found much higher
levels in the United States. This may reflect changes in societal attitudes to-
ward sex in general and sex in the elderly. Marshall and Katz (2002: 53) note
that sex researchers from the 1960s through the 1980s advised that “sexual
activity, particularly sexual intercourse, [was] a healthy and necessary compo-
nent of successful aging. Indeed, the passive acceptance of age-related changes
in sexual capacity that had characterized the professional advice of the past,
now became viewed as… pathological….” However, there were some real prob-
lems in sampling bias in this earlier sex research with aging populations. Some
researchers have relied on reports from senior centers and others only from
married partners (Riportella-Mueller, 1989: 214). There is also a bias in the
literature on Caucasians that still occurs with even the more contemporary
inquiries (DeLamater and Sill, 2005).
The more recent research has taken more sophisticated perspectives, al-
though the findings confirm that there is a decline in sexual activity as peo-
ple age and that desire and interest decline as well; this does not mean that
older people are not having sex or that the kind of sex they are having isn’t
pleasurable. Extrapolating from Tiefer (2004, 2006a) and emphasizing some
of the points made by DeLamater and Sill (2005), we can offer some of the
bio-psycho-cultural influences likely to affect desire, experience, and behavior
in the elderly. These may be applied to aging populations as well as general
influences on the quality and expression of sexuality:
• Biological factors: health, physical fitness, and illness in both the indi-
vidual and/or partner, including local or systemic conditions such as the
endocrine system, the vascular system, arthritis, cancer, disability, the side
effects of medications and medical treatment, and substance abuse.
• Psychological factors: past sexual experiences, emotional well-being, per-
sonality characteristics, and beliefs/feelings/attitudes about sex and aging.
• Partner factors: quality and length of the relationship, opportunity for sex
with a partner. The sex ratio for single women to single men over sixty
makes it more difficult for heterosexual women and gay men to find a
partner since women outnumber men significantly in aging populations
(women outlive men by around five years).
• Socio-cultural factors: cultural beliefs about aging and sex, including the
influence of ethnicity, religion, sexual cultures, gendered norms, sexual
norms, ideologies of the body including the aging body, income level, etc.
Only more recently have cross-cultural and international comparative data of
aging men and women become available. The Global Study of Sexual Attitudes
and Behaviors funded by Pfizer includes in-person and telephone interviews
with 27,500 men and women aged forty to eighty years old from twenty-nine
countries (Laumann et al., 1994, 2006). This research will be discussed. Several
other large surveys have been conducted in the United States. The American
Association of Retired Persons (AARP) has undertaken two major studies on
midlife and aging, both for AARP’s Modern Maturity Magazine, which in-
cludes representative samples. One was reported in l999 (see Jacoby, 1999) and
the other in 2009, “Sex, Romance and Relationships: AARP Survey of Midlife
and Older Adults.” This 2009 sexuality research surveyed 1,670 adults aged
forty-five years and older. As a consequence of this survey, comparative data
with the AARP 2004 representative sample was provided; however, different
methodologies make these comparisons limited. Yet another study was con-
ducted by the National Council on Aging (Dunn and Cutler, 2015). Clearly
sexuality and aging is an expanding field for research since the number of US
elderly has grown exponentially as the baby boomers have aged.
Highlights of the AARP’s “Sex, Romance and Relationships: AARP Sur-
vey of Midlife and Older Adults” are presented along with data comparing the
2009 research with the 2004 AARP sex survey where applicable. This infor-
mation targets the ages of forty-five through seventy-plus years. Additional in-
formation on sexual desire compared by gender and age follow these findings.
• Twenty-eight percent of all respondents (with a sexual partner) have in-

tercourse at least one time a week (2009: 2).
• Eight percent of the males and 2 percent of the females report a same-sex
partner (2009: 2).
• The 2009 respondents report more self-pleasuring (22 percent) in contrast
to the 2004 survey (20 percent) (2009: 2).
• Forty-three percent of respondents reported they were satisfied with their
sex life in 2009 compared to 51 percent in 2004; this varies by age with
those that are younger reporting more satisfaction, and men more dissat-
isfied than women (2009: 3).
• Forty-four percent of respondents engaged in sexual touching and 58 per-
cent hug or kiss regularly (2009: 2).
• Percent of respondents who agreed with the statement “People should not
have a sexual relationship if they are not married” dropped from 34 per-
cent in 2004 to 22 percent in 2009 (2009: 2).
• Sexual satisfaction is associated with better health and physical activity;
those with partners are more satisfied with their sex lives and life in gen-
eral across the ages and genders.
• Hispanic populations aged 45 prioritized sexuality and expressed a more
positive outlook on life compared to the general population (2009: 6).
• Prevalence of high cholesterol in women and back pain across all genders
has increased slightly since 2004 (2009: 14).
• Twenty-three percent of men were diagnosed with erectile dysfunction
(2009: 13).
• Men are more likely to use a sexo-pharmaceutical than women to improve
sexual functioning (2009: 16).
• Twenty-nine percent of men and 13 percent of women indicated problems
with sexual functioning (2009: 13).
• Sex is more important to men’s quality of life than women’s, particularly
as they age (2009: 9).
Aging Men in the United States

There are a number of changes that occur in the experience of sexuality as
men age that reflect biological, psychological, and cultural influences on the
individual. Sexual functioning and desire/sexual interest represent two major areas
of sexuality that undergo change as men age. These are interrelated, and have
been translated into hetero-normative mechanistic approaches and have been
phallocentrically defined in terms of erection and penetration (i.e., number of
times penile-vaginal intercourse occurred), rather than more nuanced approaches
that are explored more recently (DeLamater and Sill, 2006; Tiefer, 2006).
Masters, Johnson, and Kolodny (1982: 170) reported some of the following
changes in men over the age of fifty-five, representing their more biological
emphasis on human sexual response.
• It usually takes a longer time and more direct stimulation for the penis to
become erect.
• The erection is less firm, less full, and less vertical.
• The amount of semen is reduced, and the intensity of ejaculation is lessened.
• There is usually less physical need to ejaculate.
• The refractory period—the time interval after ejaculation when the male
is unable to ejaculate again—becomes longer.
As a result of the medicalization of men’s sexual dysfunction, an increasing

number of aging men are interpreting changes in erectile functioning as a dis-
order or dysfunction (Marshall and Katz, 2002; Tiefer, 2004, 2006a). It is very
important for individuals to have some awareness of the physiological changes
in the sexual aging process and to understand the diverse influences on desire,
erectile capability, and sexuality. The process of aging sexual expression is tied
into the general features of the physiology of aging in which the body expe-
riences an overall slowing down. The concomitant slowing down of sexuality
should not be looked upon as an end to sex or as a dysfunction (although for
some it may be viewed as a problem), but as a change in one’s sexual expression
and behavior. In Chapter 12, we discussed the medicalization of male sexuality
as well as the nexus of sexo-pharmaceuticals such as sildenafil, vadenafil, and
tadalafil (Viagra, Levitra, and Cialis) and related products. In the 1999 AARP
sexual survey only 5 percent of the men had tried Viagra (it had been available
only less than a year). By 2004, with Cialis and Levitra, as well as other new
technologies, the use of erectile aids had more than doubled. Sixty-eight per-
cent of the men in the AARP 2004 survey noted that their sexual satisfaction
has been increased as a result of the availability of sexo-pharmaceuticals and
recent erection-enhancing technologies (Jacoby, 2005). Jacoby (2005: 1) argues
that Baby Boomers have created yet another sexual revolution, embracing an
attitude that “health- and age-related physical problems should be treated and
overcome rather than accepted as part of growing older” (also Marshall and
Katz, 2002). Only 5 percent of men in the AARP’s 2009 survey indicated that
they took medication to improve sexual functioning; data was not collected on
satisfaction with sexo-pharmaceuticals (Fisher et al., 2010: 16).
Viagra and its cohorts can be life-threatening for men with low blood
pressure taking nitrate medications. Other side effects include head-
aches, upset stomach, and visual problems. Prior to Viagra, men’s choices
for erectile problems included vaccum devices (pumps), injections, and
penile implants of various sorts.
We recognize that for many men and their partners, these drugs and/or the
various technologies to facilitate erection have reinvigorated their sexual
relationships. While there is literature that debates how female partners re-
spond to sildenafil, vadenafil, and tadalafil (the literature is relatively silent on
same-sex partners), the 2004 AARP survey indicated that women of all ages
reported their own satisfaction was enhanced with the partner’s use of silde-
nafil and its cohorts, with some increase in amount of sexual activity as well.
Montorsi et al. (2004) indicate partners of men who use sildenafil are equally
as pleased with treatment outcomes; however, partner perspectives are not
widely included in the current literature, nor are discussions about the emo-
tional and relational impacts of using sexo-pharmaceuticals (Potts et al., 2003:
698). It must be remembered that desire and sexual interest are not impacted
by these drugs. There may be indirect psycho-social expectations that impact
the effect of these drugs, which according to Jacoby (2005: 1–3) is probably
why 42 percent of the men discontinued using sildenafil and its cohorts.
At this point, we should recall a few points about the history of “impo-
tence,” or erectile problems and its relations to men’s norms. Generally speak-
ing, before the invention of Viagra and its successors, Tiefer (2004, 2006a) and
Marshall and Katz (2002), among others, have argued that a gradual decline
in desire and erectile capability was regarded as a normal part of the aging
process. Couples in intimate relationships adjusted their sexuality in various
ways, focusing more on the total body experience. However, the last twenty
years have witnessed an escalation of the notion of “an ageless sexual vitality”
embedded in trends in medicalization of both age and sex, including the in-
vention of sildenafil and its cohorts, contributing to a continued emphasis on
sexual performance for men (Tiefer, 2004, 2006a: 7).
As a voice of resistance to these views, Castleman’s Great Sex: A Man’s

Guide to the Secret Principles of Total-Body Sex (2004: 2) exhorts men to:
“Stop trying to imitate what you see in pornography—the rushed, me-
chanical sex that’s entirely focused on the genitals. Instead, cultivate the
opposite of porn: leisurely, playful, creative, whole-body, massage-based
lovemaking that includes the genitals, but is not obsessed with them.”
The latter part of the twentieth century and the new millennium have wit-
nessed the growing hegemony of masculine gender norms that equate sex with
performance and an unrelenting and unfailing sexual desire. Viagra and its
cohorts have had a tremendous impact on aging men who have experienced
changes in erectile functioning. And these changes have more recently been
interpreted as sexual dysfunctions rather than as part of the process of sexual
aging in which libido and erectile functioning decrease (Marshall and Katz,
2002). This should not be interpreted to mean that sexual dysfunctions are not
real to men. Rather, it is suggested that a more multidimensional approach is
required to understand men who experience serious problems with sexuality
and erection related to lifestyle, health, disease, disability, and medications such
as antidepressants. Suffice it to say that there are psychological, relational, and
cultural factors in sexual problems throughout the life course, not just among
aging men (Tiefer, 2006a, in particular refer to the section, “A New View Classi-
fication of Sexual Problems”). In addition to issues related to aging erectile func-
tioning, a separate but related matter is sexual desire throughout the life course.
Changes in sexual desire are also part of the aging process for men as well as
women that are best viewed from the holistic stance of a biological, psycholog-
ical, and cultural perspective (DeLamater and Sill, 2005). Desire has also been
medicalized as we discussed in Chapter 12 (hypoactive sexual desire disorder)
(Meuleman and Van Lankveld, 2005). In contrast to men, the aging process
for women’s sexual and reproductive life is marked by a clear physiological
change that culminates in the cessation of menses (menopause). However, a
male counterpart to menopause has recently been identified and “named” in
late twentieth-century Euro-American scholarly and media discourses. This
has been variously designated as the male climacteric, male menopause, and/
or andropause. Sperm production gradually declines through the male life
course so that by age seventy-five a man may be producing only 10 percent of
the sperm he produced before age thirty (Kelly, 1990: 58). Although women
lose significant amounts of estrogen and progesterone as they age, and men’s
levels of testosterone do decline, how much and with what impact does the
decline in testosterone have on sexual desire and interest? In addition, there
is a great deal of variation among men that may include genetic as well con-
text-specific factors such as medications (Angier, 1992; Marino, 1993; Vermeu-
len, 2000). With the FDA approval of a testosterone gel (Androgel) in 2002,
there has been a substantial increase in men being treated with testosterone
therapy for low sexual desire/interest, and for other related reasons including
mood, energy levels, etc. Provision of testosterone therapy has increased five-
fold since 2011 (McBride et al., 2016: 47). Testosterone “therapy” has been
escalating in the United States since the introduction of user-friendly gels and
patches, as opposed to injections, and has led the National Institute of Aging
to register concerns about the risks and benefits of testosterone treatments
(“NIA Statement on IOM,” 2003). The variability of testosterone therapy in
aging men makes the prescription of testosterone difficult, and more research
needs to be done before its widespread use (Ahern and Wu, 2016: 193).
Studies offer conflicting views on testosterone production in aging men.
After thirty years of age, testosterone levels can decrease by 0.4–2 percent an-
nually (McBride et al., 2016: 47). Vermeulen (2000) notes that by seventy-five
years old, average testosterone levels are only 65 percent of those of young
adults; while 25 percent of the men over seventy-five still have testosterone
levels in the upper range for young men. Tan and Culbertson (2003) assert
that between the ages of twenty and eighty men’s testosterone levels decline
by about 35 percent. The Baltimore Longitudinal Study of Aging (Harman
et al., 2001) on 890 older men found age-related reduction in testosterone lev-
els but these lower levels were not universal, affecting about 20 percent of men
aged sixty, 30 percent of men over seventy years old, and 50 percent of the
men over eighty years old. Evidence suggests that low testosterone is not that
common; Sartorius et al. suggest that decrease in testosterone levels may be
attributed to co-morbidities associated with aging, and not the process of aging
itself (2012: 760). Furthermore, The National Institute on Aging (“Frequently
Asked Questions about Testosterone,” 2003) states:
There is scant evidence that “male menopause,” a condition supposedly

caused by diminishing testosterone levels in aging men, exists. As men
age, their testes often produce somewhat less testosterone than they did
during adolescence and early adulthood, when production of this hor-
mone peaks. But it is important to keep in mind that the range of normal
testosterone production is large. Many older men have testosterone levels
within the normal range of healthy younger men. Others have levels well
below this range. However, the likelihood that a man will ever experience
a major shut down of hormone production, similar to a woman’s meno-
pause, is remote.
In fact, many of the changes that take place in older men often are
incorrectly blamed on decreasing testosterone levels. Some men who have
erectile difficulty may be tempted to blame this problem on lowered tes-
tosterone. In many cases, erectile difficulties are due to circulatory prob-
lems, not low testosterone.
Changes in men’s sexual desire as they age may be highly variable and inter-
connected to a number of factors which may include physiological influences
related to the endocrine system, health and illness, medications and medical
treatments. DeLamater and Sill’s (2005) research using data from the AARP
1999 survey of people over age forty-five found that the chief influences on
sexual desire for men were age, education, and the importance of sex to the in-
dividual. For both men and women, DeLamater and Sill conclude “attitudes are
more significant influences on sexual desire than biomedical factors” (2005: 138).
Though there may be no profound and documented major changes in hor-
mone levels before eighty years old, this does not mean that the masculine
climacteric in the United States is a myth. A male climacteric or midlife crisis
is a culturally acknowledged period in the industrialized man’s cycle where
he may experience a variety of symptoms including anxiety and depression
(Henker, 1977 in Kelly, 1990: 58; Masters, Johnson, and Kolodny, 1982: 170;
Moss, 1978; Vermeulen, 2000). The “male menopause” may in fact be a re-
sponse to the cultural conception of aging dominant in the United States.
This is a period where the male, whose patriarchal culture has encouraged,
advantaged, and celebrated him, confronts a mitigating cultural feature: the
youth orientation of US society. The aging man must face the inevitability of
aging and the profound changes in status and prestige that may accompany it.
The “male menopause” may well be a response to this male dilemma, for ours
is not a society that venerates the elderly.
Whether a man experiences a social phase like “andropause” will vary
cross-culturally, depending on the cultural meanings embedded in the partic-
ular society’s ideology of aging, and the definitions and expectations regarding
masculinity (Winn and Newton, 1982).
Societal attitudes about “dirty old men” may do much harm to the aging
man’s self-esteem. Industrialized society’s ideal cultural standards set a very
narrow age range for socially approved periods of sexual behavior. Sexuality is
denied to the young as well as the very old in the United States in the ideal
cultural norm. This reflects the traditional value on sex for procreation. If our
model of sexuality was purely recreational, and not so phallocentric, elderly
sexuality would probably be championed for the changes it produces. The el-
derly man as well as woman who wishes to continue to experience his or her
sexuality may be the brunt of jokes and other sanctions among industrialized
Anglos. Ageist attitudes regard sex as if it is something that should be out-
grown among the elderly. That this damage may be first expressed through the
ideologies of a male climacteric in anticipation of these cultural attitudes also
reflects the reproductive success model of sexuality.
Aging Women in the United States

By 2015 in the United States, 50 percent of American women were in meno-
pause (“Alternatives to HRT for Treatment of Menopausal Symptoms,” 2005).
The majority of US and European women experience menopause between
the ages of forty-five and fifty-five, with a median age fifty to fifty-two (Avis
et al., 2009). The time period surrounding menopause includes the period of
perimenopause, also referred to as the climacteric. It usually begins around five
years prior to and after the last menstrual cycle, covering a period of about ten
years (Northrup, 2001; North American Menopause Society). Menopause is
the cessation of menstruation that occurs as a result of decreasing hormone
production of estrogen and progesterone by the ovaries; production of testos-
terone by the adrenals eventually decreases along with other age-related endo-
crine and other system changes. Over a period of time, a woman’s menstrual
cycle becomes increasingly irregular, although there are some women whose
menstrual cycle just stops. However, because the climacteric is generally a pe-
riod of irregularity, using birth control for a year after the cessation of men-
struation is advised (“Menopause—Another Change in Life,” 2006; North
American Menopause Society; Planned Parenthood of America).
In industrialized Anglo populations, menopause is associated with a vari-
ety of psychological and physical changes. It is difficult to separate cultural
myth from reality regarding the psychic and emotional changes reported with
perimenopause and menopause given the industrialized fascination with rag-
ing hormones. A number of issues and factors have been identified with per-
imenopause. Menopause has been increasingly medicalized in the twentieth
and twenty-first centuries, so it is not surprising that menopause has been
concomitantly considered a syndrome with symptoms (Tiefer, 2004). Medical-
ization may be regarded as part of the Euro-American industrialized lens that
shapes how women experience menopause. We have listed some of the more
prominent health and psychological effects associated with perimenopause
and menopause in US society. This list is often referred to in the literature as
“symptoms.” A medicalized perspective attributes these “symptoms” to the de-
cline in female hormones, specifically estrogen and progesterone. This list that
follows was created from a number of sources including: Avis et al., 2001, 2003;
“Fact Sheet: Hot Flashes,” 2006; King, 2005; “Menopause—Another Change
in Life,” 2006; Vilet, 1993: 14–16; and Ward, 2006. Complaints and physiologi-
cal changes of industrialized menopausal women include the following:
• Headaches.
• Difficulty concentrating/changes in memory.
• Joint pain.
• Palpitations.
• Frequent urination.
• Night sweats.
• Insomnia/disrupted sleep.
• Vaginal dryness (lubrication is significantly reduced).
• Thinning of the vaginal walls and loss of vaginal elasticity.
• Lack of energy.
• Decline in sexual desire.
• Changes in sexual response with fewer orgasmic contractions.
• Increased risk for osteoporosis.
Keep in mind as you view this list that there is compelling research to suggest
that many of the physical changes and “symptoms” of menopause as well as
how women experience menopause, are in fact influenced by socio-cultural
variables linked to women’s status, the meaning of aging, sex, and reproduc-
tion (Avis et al., 2001; Richters, 1997; Ward, 2006). For example, the Inis Beag-
eans, an Irish community noted for their repressive sexual attitudes, believed
that one of the consequences of menopause is mental illness, so that some
of the physiological symptoms reported among industrialized women such as
hot flashes and mood swings were regarded as signs of insanity. According to
Messenger who studied this community some women have “retired from life
in their mid-forties and, in a few cases, have confined themselves to bed until
death, years later” (1971: 15). Psychological and physical changes associated
with menopause are not experienced uniformly across cultures (Ward, 2006).
We shall return to this topic shortly.
It is sometimes difficult to assess whether some of the uncomfortable sen-
sations older women experience are related to the cessation of fertility and
decline in estrogens, progesterone or with aging generally. Nevertheless, med-
icalization of menopause has been escalating since the first “treatments” for
menopause with estrogen and progesterone, referred to initially as estrogen
replacement therapy (ERT) and later coming to be known as HRT, hormone
replacement therapy. HRT has more recently been called menopausal hor-
mone treatment (MHT) by the National Center for Complementary and
Alternative Medicine, the National Institutes of Health.
Robert Wilson’s (1962) research on prescribing estrogen and progesterone
for menopausal women jump-started the US and industrialized use of MHT
(King, 2005). Wilson claimed MHT was a miracle drug and pronounced “Step-
ford Wife” results, claiming MHT would preserve women’s youth and sexual vi-
tality: “[e]strogen makes women adaptable, even-tempered, and generally easy
to live with” (in King, 2005: 320). The widespread use of MHT contributed
to the medicalization of menopause as a syndrome with symptoms that can
be “fixed” with medication. One of the consequences is that these symptoms
contribute to a negative view of women’s aging, one that is exacerbated by US
and industrialized emphasis on youth culture and women’s lower status com-
pared to men. In addition, according to Tiefer (2004), the medicalization of
menopause has been escalated by the growth of capitalism and the expansion
of pharmaceutical companies and health care nationwide and internationally
(Tiefer, 2004). This is certainly not the “menopausal zest” that Margaret Mead
associated with women’s renewed sense of energy that occurred in some soci-
eties as women experienced freedom from fulltime duty as mothers/spouses (in
Ward, 2006: 75). We shall return to the topic of the influence of culture on the
menopausal experience.
Hormone Replacement Therapy/Menopausal Hormone

Treatment (MHT)
Since the mid-1960s, HRT was widely prescribed to industrial women to in-
tercede in the “symptoms” of menopause. Wide claims were made as to the
benefits of MHT for hot flashes, sleeplessness, lack of lubrication, painful
intercourse related to lack of lubrication, the thinning and loss of elasticity
of the vaginal walls, diminished libido, hair loss and thinning, osteoporosis
(the thinning of bones), loss of memory and concentration, and mood. It also
promised health benefits such as the reduction in cholesterol (which it does
do) and reducing the risk of heart attack (which it doesn’t and actually may
put users at higher risk). Research demonstrates that MHT does improve some
of the menopausal effects associated with declining sex hormones associated
with aging (“Fact Sheet: Hot Flashes,” 2006). According to the National In-
stitute on Aging (“Age Page: Hormones after Menopause,” 2005) it does ease
symptoms of hot flashes, vaginal dryness, reduces the risk of osteoporosis and
colorectal cancer. However, a 2002 report by the Women’s Health Initiative
(WHI) challenged whether these benefits were worth the health risks posed by
MHT. In 1993 less than 15 percent of menopausal women used MHT (Utian
et al., 1993: 16), but by 2002 about 38 percent of the women were using MHT
(“Menopause Management in Light of the Women’s Health Initiative,” 2006).
Sponsored by the National Institutes of Health, the Women’s Health Initia-
tive was a large study launched to investigate the use of MHT, since research
had begun to link estrogen replacement therapy with risks for breast and
uterine cancer (Boston Women’s Health Collective, 1992; Utian et al., 1993).
This was a nationwide randomized and controlled study of 27,347 menopausal
women using MHT including estrogen-only therapy, and those using com-
bined estrogen and progesterone over a period of eight to twelve years. The
combined MHT approach was developed for women with a uterus to offset
the potential for uterine cancer as a result of prolonged exposure to estrogen.
In 2002 the WHI study was abruptly stopped after only 5.6 years in order to
report to the US public empirical findings of the increased health risk MHT
posed to women. Subsequently the estrogen-only study was stopped in 2004
after a little over seven years.
The risks for MHT combined treatment included: heart disease, breast can-
cer, stroke, and blood clots among women who had long-term use of these
treatments. The estrogen-only research found increased risk for stroke, a sim-
ilar risk to the combined study (“Fact Sheets: Menopause and Heart Disease,”
2006). According to the WHI the risks for every 10,000 women using a com-
bination estrogen/progestin MHT are:
• Eight more cases of breast cancer than in women not using MHT.
• Seven more cases of heart disease.
• Eight more cases of stroke.
• Eight more cases of blood clots in the lungs (“The Age Page Hormones
after Menopause,” 2005).
However, current research critiques the response to the WHI study, stating
that the absolute risk of CVD in younger women who start HRT at the onset
of menopause is not significant enough to discontinue its use in managing
menopausal symptoms (Chester et al., 2018: 251), and that the early closure
of the 2002 trial resulted in a loss of valuable research that could have been
useful in dispelling displaced fears about using HRT (Cumming et al., 2015:
57). An Internet survey of post-menopausal women from the UK found that
43.8 percent of respondents did not feel that they knew enough about HRT to
make a decision regarding its use. While this improved from 2004, where 73
percent of surveyed women indicated the same, the benefits and risks in using
HRT remains a poorly discussed topic between clinicians and their patients
(Cumming et al., 2015: 60).
As a result of the WHI studies, medical practitioners became alerted to
possible health risks and consequently carefully began to monitor MHT for
clients. FDA guidelines recommend that the lowest dose for the shortest pe-
riod of time is the best way to proceed. Even with low dosages the health risks
are not known. Some women have switched to what are called bio-identical
hormones, chemically tweaked estrogens and progestins that are akin to the
naturally occurring ones (Northrup, 2001); however, the health risks of using
bio-identical hormones have not been established and remain a contentious
debate in the medical community (Boothby et al., 2008: 406; Mukkamala,
2016: 5). In addition, the health effects of “natural” supplements derived from
plant estrogens that are not under FDA control have not been studied scien-
tifically. Women are advised to consult with their healthcare providers and
to weigh the risks and benefits of MHT. If they do decide to use MHT, then
it should be regarded as a short-term and temporary treatment (Barcaly and
Vega, 2005).
As a result of the WHI findings, US/industrialized women and their medical
practitioners have gone in quest of alternative and “natural” treatments, as
well as lifestyle changes, including diet, exercise, and the use of vitamins and
supplements to reduce some of the more uncomfortable effects of menopause.
However, a cache of other pharmaceuticals is also currently prescribed in place
of MHT to counteract menopausal effects including antidepressants used off
label to reduce hot flashes and anti-inflammatory drugs for joint pain, among
others. These drugs also have detrimental side effects that must be consid-
ered when weighing the decision regarding menopausal effects and treatments
(Parker-Pope, 2006). The natural and alternative approaches including vita-
min therapy suggest that to reduce the risk of osteoporosis, menopausal women
should take calcium and vitamin D. Regular weight-bearing exercise is also
advocated for strengthening bones. In addition, women and their healthcare
providers are pursuing CAM: complementary and alternative medicine. The
following points regarding menopause and treatments to alleviate symptoms
are made by the National Center for Complementary and Alternative Med-
icine of the National Institutes of Health (“Do CAM Therapies Help Meno-
pausal Symptoms?” 2005).
• Many women have few or no symptoms related to menopause or feel

that their symptoms are not enough of a problem that they need to seek
treatment. Some symptoms traditionally seen as menopausal may be re-
lated to aging in general.
• Menopause should not be viewed as a disease.
• For many years, menopausal hormone therapy was the primary treatment for
troubling menopausal symptoms. Recent studies have found increased risks,
however, for certain serious health problems from prolonged use of MHT.
• Women with severe or long-lasting symptoms of menopause that have not
been adequately relieved in other ways should consult their healthcare
providers about their personal risks and benefits for using MHT. Certain
lifestyle changes can also be helpful.
• There is very little high-quality scientific evidence about the effectiveness
and long-term safety of CAM therapies for menopausal symptoms. More
research is needed.
• It is very important for women who are considering or using CAM thera-
pies for any health concern to discuss them with their healthcare provider.
This is to help ensure safety and a comprehensive treatment plan.
Since the Women’s Health Initiative results were first reported in 2002, closer
scientific scrutiny of the research findings has offered challenges to the study
for its flawed design (Klaiber, Vogel, and Rako, 2005). For example, the health
risks of MHT were primarily associated with the much older women (ages fifty
to seventy-nine years old) who began taking hormones with little or no prior
history of MHT. This biased the results of MHT because the older population
was more at risk for coronary and cerebral atherosclerosis due to their age.
The younger women who began MHT at menopause had far less risk, with
some evidence that MHT may actually offer some safeguards for heart health
(Klaiber, Vogel, and Rako, 2005; Parker-Pope, 2006). Current clinical guide-
lines suggest that MHT is safe for women younger than age sixty or within
ten years of menopause with no history of cardiovascular disease, embolisms
or breast cancer (Stuenkel et al., 2015: 3976). Despite this, the use of MHT
to treat menopausal symptoms has decreased by 80 percent since its initial
publication in 2002. This is partly due to a failure to adequately train medical
students to identify and treat menopause in female patients (Santen et al.,
2014: 281). Menopausal women are encouraged to weigh their options carefully
and to consider the risks and benefits of not only MHT, but also the use of sup-
plements that are not scrutinized by the FDA for safety. No relevant medical
society in the United States currently endorses the use of alternative hormone
therapies (Gass et al., 2015: 1277).
Biological, Psychological, and Cultural Perspectives on

Menopause
One of the consequences of the WHI report is that by declaring the dangers
of MHT (although the results have been critiqued), it has enhanced the posi-
tion that menopause is a normal part of the aging process. Again, a biological,
psychological, and cultural lens allows us to see how physiology intersects with
the individual through culture. The Boston Women’s Health Collective has
argued that the only universal physiological changes in menopause are loss of
fertility, vaginal thinness and loss of lubrication, and vasomotor changes or
“hot flashes” (1992; also Greer, 1992), while other research has included long
lists of menopausal “symptoms.” These “symptoms” reflect the confluence of
the process of medicalization as well as United States cultural beliefs about
aging in a society with an imposing youth culture. In reviewing this literature
Avis et al. (2001: 4) note that the research includes lists of symptoms of meno-
pause ranging from 20 to 26 characteristics.
Two lines of evidence argue against a medicalized view that menopausal
effects on the body are due primarily to decline in “female” hormones and
that menopause is a medical syndrome with associated symptoms. Cross-cul-
tural research of nonindustrialized menopausal women and research including
ethnicity has interrogated these notions. Research from India by Flint (1975)
reported none of the problems with menopause that industrial women re-
ported (in Avis et al., 2001). Research on Japanese women by Lock (1993)
and Avis et al. (2001) found a low occurrence of hot flashes and night sweats,
along with lower numbers of other somatic and psychological effects in com-
parison to Canadian and US women (Avis et al., 2009). Variation in the ex-
perience of women globally argues strongly that the meaning of menopausal
effects (psychological and physical) is interpreted through a cultural lens.
For example, Beyene’s (1989) study of Greek and Mayan women suggests
that hot flashes are not regarded as necessarily problems to be treated. While
hot flashes are viewed as a common “symptoms” of industrialized women’s
menopause, cross-cultural studies indicate that hot flashes and other effects
are not as pronounced among Japanese; Indian women (Avis et al., 2001);
Mayan women (Beyene and Martin, 2001); and Greek women (Beyene,
1989). For women cross-culturally, what hot flashes mean is given a cultural
message (Ward, 2006). We shall discuss the cross-cultural record in more
depth at the end of this section.
Another line of evidence that challenges medicalized views of menopause is
Avis et al.’s (2001) research of the “symptom groupings” associated with meno-
pause. Until Avis’s research, the literature on menopause had supported a view
that symptoms of menopause group together to create a universal menopause
syndrome. Unfortunately, the evidence for this view was from a primarily
Caucasian sample. Avis et al. (2001) conducted research across five racial/eth-
nic groups to investigate how “symptoms” associated with menopause cluster
(i.e., irritability, forgetfulness, etc.). In this research, Avis and colleagues ex-
trapolated ten symptoms from the literature on menopause and investigated
these among a sample of 14,906 women from the ages of forty through fifty-five
including those who self-identified as Caucasian, African American, Chinese,
Japanese, and Hispanic. This research was designed to test empirically whether
or not there are associations between symptoms of menopause and how these
vary by race/ethnicity.
This research asserts that there is an incredible diversity in how women
experience menopause and that there are some ethnic (cultural) differences as
well; for example, Asian women reported the fewest symptoms of all the ethnic
groups. Further investigation to determine if this might be due to a soy rich
diet has been suggested. Avis et al. (2000: 16) concluded that
[t]he lack of a single set of menopausal symptoms and the findings that the
type and number of symptoms vary with race/ethnicity attest to the need
to continue to explore the complex relationship between the physiological
changes occurring during menopause and the symptoms experienced by
women.
Avis and colleagues’ findings by ethnicity/race are:
• African American women were more likely to have surgical menopause.

• MHT was highest among Caucasian and lowest among African American
and Hispanic women.
• Chinese and Japanese women were less likely to report feeling tense, de-
pressed, and irritable, with headaches and stiffness.
• Compared with Caucasian women, all other racial/ethnic groups of
women report far fewer symptoms (2001: 345–356).
In assessing the interaction of biological, psychological, and cultural influences

on menopause, hormones alone cannot explain the diversity as well as sys-
tematic differences in how women experience menopause across ethnicities
and cultures. Regretfully, Avis et al. (2001) did not explore the issue of sexu-
ality. There is a great deal of cultural heterogeneity in how women interpret
the body’s response to diminished hormones with regard to sexuality (as we
shall discuss further in the section “Aging and Sex: International and Cross-
Cultural Evidence”).
How can we account for the negative symptoms associated with perimeno-
pause and menopause among Caucasian women? Judith Brown argues that this
is related to the general status of women in industrialized societies. She argues
that industrial women have few restrictions in early life, so there is less to look
forward to in old age. An increasingly youth-oriented culture structures our ex-
periences of menopause as negative. In fact, a number of menopausal somatic
and psychological effects can be explained by the other changes occurring in
the industrialized woman’s life co-terminously including stress about aging and
increasing invisibility in a culture that has no mature models of sexual beauty
and attractiveness. Additional factors impacting menopausal women’s stress is
that American society emphasizes instant gratification (aided by technology),
has little tolerance for discomfort and inconvenience, and expects fifty-year-
old people to perform at the same level as they did in their twenties and thir-
ties. We shall discuss specifically how these relate to issues of sexuality among
aging and menopausal women separately.
Sexuality and Menopause in the United States
To understand women’s menopausal sexual experiences requires that we ap-
proach the topic from a bio-psycho-cultural perspective that integrates “A
New View of Women’s Sexual Problems” in the analysis (Kaschak and Tiefer,
2001; Tiefer, 2004). We have described “A New View” and the medicaliza-
tion of sexual problems in Chapter 12. This perspective is also applicable to
understanding menopausal women’s sexual expression and experience. For
example, a menopausal woman’s lack of desire for penetrative sex and the
cessation of penetrative sex behaviors must be considered holistically. One
consequence of declining estrogen levels is that thinning of the vaginal walls
occurs along with reduction in elasticity and a substantial reduction of vag-
inal lubrication. Both these factors may result in painful intercourse and
consequently the decline and loss of a desire to have penetrative sex. How-
ever, external lubricants and a leisurely and whole-body approach to sex can
make a huge difference. There are a number of over-the-counter lubricants
available (“CME Alternatives to HRT for Treatment of Menopausal Symp-
toms,” 2006). Finally, a perspective that emphasizes the multiple dimensions
of women’s sexuality is especially important. Declining frequency of pen-
etrative sex does not mean that menopausal women are not encountering
pleasure in sexual expression but may be finding that pleasure in other not
so genitally focused ways. This perspective emphasizes more humanistic ap-
proaches that consider menopausal women’s sexual experience in a holistic
context including the partner and the relationship, socio-cultural factors,
and psychological components including past sexual experience and medical
conditions. We must be alert to critique a medicalized and biocentric model
that looks at menopausal women as having a syndrome that is related to a no-
sology of sexual dysfunctions that is consequently treated with medication/
hormones (FSD-Alert, 2005; Tiefer, 2004). Menopause is not “estrogen defi-
ciency” disease.
A more recent trend in pathologizing menopausal women has been
through the search for a “female Viagra.” Although a woman’s sexual re-
sponse has proven too complicated for a “quick fix” like Viagra, the trend has
been to explore drugs to enhance women’s sexual desire, rather than genital
blood flow (Hartley, 2005). This strategy has emphasized hypoactive sexual
desire disorder and turned to testosterone “treatment” as a solution. With
a huge baby boomer population in menopause, and with decreasing testos-
terone as part of the endocrine changes occurring in menopausal women,
this line of investigation proved very promising for pharmaceuticals. With
the potential for a very large number of menopausal women with a medi-
calized “testosterone deficiency syndrome” in the offing, the development of
testosterone replacement therapies began. This has resulted in an increase
in off-label prescription of male testosterone therapies (e.g., Andro-Gel, Tes-
tim) for menopausal women complaining of low libido. It has been estimated
that one-fifth of all off-label prescriptions for testosterone are for women,
reflecting the influence of pharmaceutical companies (also FSD-Alert, 2005;
Hartley, 2005). In 2004, Proctor & Gamble tried to get approval for Intrinsa,
a testosterone patch for women. The FDA unanimously turned down ap-
proval on the basis that there has been no empirical research demonstrating
a clear link between low sexual desire and low testosterone in women. There
was insufficient evidence of the health risks posed to menopausal women
who were the prime target market, and no data on long-term use (“Con-
cerns about New Hormone Treatments for Women,” 2004; DeLameter and
Sill, 2005; Hartley, 2005). Methyltestosterone with estrogen is a combination
pill that blends estrogen and testosterone. This treatment has come under
increasing scrutiny as well since the FDA has not approved this drug. The
Women’s Health Network has called for the FDA to disallow prescriptions
of Solvay’s Estratest and Breckenridge’s Syntest since there is no evidence
documenting safety and effectiveness in relieving hot flashes (“Group Asks
US FDA to Stop Sales of Hormone Combo,” 2006). Off-label prescription of
methyltestosterone with estrogen includes treatment for low sexual desire in
menopausal women as well. Bancroft, Loftus, and Long (2003) report that
there is a great deal of variation among menopausal women in the levels
of circulating testosterone and in their reported interest in sex (“Concerns
about New Hormone Treatments for Women,” 2004).
Reports of menopausal problems in sexual desire and a related decline in
penetrative sexuality are debated in the scientific literature. In a comparison of
groups of French premenopausal women, post-menopausal women using MHT
and post-menopausal women not using MHT, all groups reported the same
level of sexual satisfaction (Ringa et al., 2013: 2403). Berra et al suggest that
although post-menopausal women do experience greater sexual dissatisfaction,
personal distress over sexual functioning is lower in this group compared to
premenopausal women (2010: 121). On the contrary, many studies have found
a correlation between increasing age and decreasing sexual satisfaction (Avis
et al., 2009: 7; Thornton et al., 2015: 8; Valadares et al., 2008: 779). Ethnic,
religious, and cultural factors play a large role in the sexual satisfaction of post-
menopausal women, making research on the relationship between post-meno-
pause and sexual satisfaction difficult to elucidate. Across a literature review
of 42 studies on sexual satisfaction in post-menopausal women, depression
and anxiety were unanimously related to sexual satisfaction (Nazarpour et al.,
2016: 487). Furthermore, smoking, alcohol use, partner loyalty, access to health
care, and understanding of women’s health all play a role in sexual function
(2016: 480).
The literature supports a number of findings about women, age, and sex-
ual desire. Psychological factors interact with cultural beliefs about aging and
gender. Relational issues are important as well as intimacy. A longitudinal
study of post-menopausal women in Australia found that women who were in
more significant, long-term relationships were more likely to experience sex-
ual distress; this was related to fears about the effect declining sexual interest
would have on the relationship (Lonnèe-Hoffmann et al., 2014: 2036). In the
United States, women’s post-menopausal age and the presence of a sexually
attentive partner are also important considerations given the gender gap in
mortality of five years between women and men (Brooks, 1993: 27–28; Renzetti
and Curran, 2003; Xu et al. 2014: 1). “Predictability of sexual activities and
over-familiarity with the partner may also contribute to a loss in sexual de-
sire” (Levy in DeLameter and Sill, 2005: 142). Lack of interest in sex may be
a coping strategy among menopausal women without a partner as well. Other
contextual factors are the physical and mental health of the individuals and
their partners. Income is also important as a quality-of-life issue and potential
life stressor in the sexual desire of menopausal women (DeLameter and Sill,
2005; Koch et al., 2005; also Tiefer, 2004 among others).
Using a large sample of 1,384 men and women, DeLameter and Sill (2005)
explored the relationships among these variables in a population forty-five
years old and older. They found that desire decreases with age, but it was not
until women reach seventy-five years old that the majority report a low level
of sexual desire. Desire is also related to attitudes toward sex and education;
education may impact negative attitudes toward sex in a more positive direc-
tion. For aging women, absence of a partner was more of a predictor of desire
than it was for men: 78 percent of the women without a partner indicated
low levels of desire, while more than 83 percent of the women with a partner
ranked their desire as high. Illness and medications also play a small role in
women’s desire. This research was biased toward Anglos and did not include
the influence of sexual history or the role of culture in framing sexual desire
among women. These findings are confirmed by the 2004 AARP Sexual
Survey, “Sexuality at Midlife and Beyond: 2004 Update of Attitudes and
Behaviors,” 2005.
One of the gender differences reported by the 2004 AARP Sex Survey is
that sex is more important to men’s quality of life than it is to women’s. In ad-
dition, 15 percent of the women say they don’t particularly enjoy sex. This con-
firms that men have engaged in more sexual behaviors and think about it more
than do women, and non-partnered women engage in fewer sexual activities
than men as well. However, loss of lubrication and thinning of vaginal tissues
and consequent discomfort may be implicated in this gender difference (“Sex-
uality at Midlife and Beyond: 2004 Update of Attitudes and Behaviors,” 2005).
Koch et al.’s 2005 research on body image and sexuality in middle-aged women
(ages thirty-five to fifty-five) found that sexual satisfaction was not related to
body image. Although they experienced body image concerns, 72 percent of
the women in her research reported they still enjoyed sex and that they were
satisfied with their sexual relationship, confirming research (e.g., Trudel, 2002)
that older sexually active women tend to report that they are satisfied with
their sexual relationships despite changes in response and activity. However,
desire and amount of activity were found to be correlated with body image (see
discussion that follows) (Koch et al., 2005).
Cross-Cultural Ideologies of Aging
Contemporary approaches to understanding the sexual experiences of mid-
dle-aged, peri-menopausal and menopausal women emphasize the importance
of psycho-cultural influences on menopause. This approach, while relatively
recent in sexology, psychology, and related disciplines, is not new to anthro-
pological research on aging and sexuality. The anthropological perspective
accents the socio-cultural context and the meanings of sexual desire and activ-
ity. The psychological and physical dimensions of embodiment are attributed
with meaning by individuals who actively interpret the messages their culture
provides, including ideologies, beliefs and practices.
Women, like men in industrial society, experience a dramatic drop in status
associated with aging. Although the US focus on youth affects both aging
women and men, unlike men, who may be compensated for the effect of aging
on their appearance by an increase in power, women as they age will be per-
ceived as less attractive since beauty is equated with youthfulness. Currently,
there are not many models available for elderly or mature beauty (although
this might change with the relative proportions of menopausal women to
reproductive women increasing over time). How can we explain the relative
devaluing of older women in the United States and some other industrial-
ized nations? This is related to gender differences in social roles for women
and men. The industrialized gender roles break down into a gender-biased di-
chotomy: an instrumental and action orientation for men, and expressiveness
and relationship orientation for women. Though gender roles are changing,
the cultural messages supporting this dichotomy still prevail in a variety of
arenas. We can summarize this dichotomy by saying men “do” while women
“display.” Women have come to be primarily defined in terms of beauty and
allure, highly visible adornments and demonstrations of men’s success (Bolin,
1992: 79–99). Sexual attractiveness and beauty norms in the United States
are generally associated with youth during the reproductive years (Koch et al.,
2005). As noted earlier, unlike many European countries and other societies
cross-culturally, the United States does not have an ideology of mature beauty
and sexual attractiveness. Our notions of beauty emphasize those in the repro-
ductive years, neither too young nor too old.
Research has only just begun to explore the relationship of decreased sexual
desire and body image. This is an underreported area for sex research and
indicates the importance of cultural attitudes on sexual desire (Koch et al.,
2005). In a study of 307 (mostly white) heterosexual women aged thirty-five
to fifty-five Koch and colleagues assert that women’s loss of sexual desire is
due more to their self-image than to hormones. Declines in sexual desire were
directly linked to self-perception as unattractive. All women perceived them-
selves as less attractive than they were a decade earlier. The more a woman
perceived herself as less attractive, the more she was likely to report a decline
in desire and sexual activity and the more attractive she perceived herself
the more likely she was to report an increase in sexual desire and activity.
Two-thirds of women reported that over the last ten years that they had ex-
perienced either a loss of desire or less sexual activity with about one-third
stating they enjoyed sex more. Thus, change was also in a positive direction,
with an increase in desire and sexual response, which Koch et al. (2005) rec-
ommend bears further investigation. Recall as well that three-quarters of a
research population reported they were sexually satisfied regardless of changes
in activity and response.
This loss of status for women as they age can weigh dramatically upon wom-
en’s self-concepts as being attractive and sexual. In addition, the same age and
sex norms are applied to women that are applied to men as they mature toward
the elderly age category. In fact Bancroft, Loftus, and Long (2003) found that
age affected women’s sexual desire and activity more than menopause per se,
illustrating the importance of age norms in framing sexual experiences (Koch
et al., 2005). Though there is no “dirty old woman” concept in the United
States, there are cultural discourses that emphasize negative aspects of mature
womanhood. Like men, women are also stigmatized for their interest in ma-
ture sexuality; this may be presented humorously, but the message indicates a
discomfort with aging sexuality. Gay men may also face a similar stigma due
to the youth orientation of the bar culture, although the degree to which this
is true for those outside this scene and lesbians remains to be determined (in
Riportella-Mueller, 1989: 222).
Elderly women may also buy into cultural notions that sex is something they
should give up. Kaas (1978) has identified this as the “geriatric sexuality break-
down syndrome” defined as a self-fulfilling prophecy for many elderly who are
responding to negative societal norms against elder sexuality. The aging indi-
vidual may come to feel guilty or even that they are deviant for their continued
interest in sexuality (in Brooks, 1993: 27, 31, 34; Riportella-Mueller, 1989: 219).
However, the medical evidence contradicts this social norm. In fact, the re-
verse is true according to Cross (1993: 177) who quips one must “use it or lose
it.” Sex is good for the sexual organs which will shrink in size if not utilized; for
example women who continued to experience their sexuality after sixty had
less trouble with self-lubrication of the vagina (Riportella-Mueller, 1989: 216).
Because women in the United States live about five years longer than men
do (Arias and Xu, 2012: 1), this has ramifications upon the sex lives of het-
erosexual women who are married to men of the same age or older. There
is an “imbalance in the sex ratio for those over 65; there are more women
than men, and more women left without partners” (DeLameter and Sill, 2005;
Riportella-Mueller, 1989: 212). This problem may be compounded by institu-
tionalization, where sex may be discouraged among unmarried residents by
formal administrative policies and by informal practices of employees in such
institutions (Walker and Harrington, 2002). Only about 5 percent of the el-
derly are in homes for the aged at any given time (Riportella-Mueller, 1989:
212), although this should not dissuade us from concern over the effects of
institutionalization on the sexual health of the elderly.
Aging and Sex: International and Cross-Cultural Evidence
Sociologist Edward Laumann and colleagues’ “Global Study of Sexual
Attitudes and Behaviors” (Pfizer, 2002) is a massive undertaking that includes
27,500 women and men from twenty-nine countries around the world. The sur-
vey includes attitudes, behaviors, beliefs, information on sexual desire, and sexual
problems among men and women from forty to eighty years old. This research
has been funded by Pfizer, the makers of Viagra. Though Laumann is a highly es-
teemed sex researcher, questions have been directed about Pfizer’s motives (e.g.,
expanding their market for Viagra) by feminist scholars, those subscribing to the
“New View of Female and Male Sexual Problems” (Tiefer, 2006a; Tiefer, Brick,
and Kaplan, 2003) and other researchers concerned about the potential for ex-
panding medicalization of sexual problems in the international sector.
Various articles, reports, and papers have been presented utilizing data col-
lected from this project; for example Laumann et al. (2006) have analyzed
sexual satisfaction across twenty-nine countries. These countries were divided
into three groups based on Laumann’s concept of sexual regimes, defined as
the way gender differences are understood in a culture. The first grouping of
countries was identified as gender-equal regimes, including Western European
countries, Mexico and non-European English-speaking countries. The second
grouping included Brazil, Islamic (Mediterranean), and selected Asian coun-
tries (such as the Philippines); these were identified as male-centered regimes
or patriarchal regimes. The third grouping included all East Asian countries
which were also identified as male-centered. This grouping system allowed for
comparisons across nations and across gender regimes.
Laumann et al. (2006) found a gender gap in sexual well-being, with men re-
porting higher levels of sexual satisfaction than women across all the countries;
this was true even in alleged gender-equal regimes (although these countries
are gender equal only in ideal not necessarily practice, like the United States).
The highest levels of sexual satisfaction were associated with the gender-equal
societies that endorsed forms of the companionate marriage. The two other
male-centered groupings of nations had lower levels of sexual satisfaction, re-
flecting, according to Laumann et al., the de-emphasis of the relational as-
pects of sex and an emphasis on the reproductive aspects of sex. All the Asian
countries were distinguished by low levels of sexual well-being, moderate to
low levels of satisfaction with their relationships, and the importance of sex in
comparison with other countries. Israeli women placed the highest value on
sex, while lowest scores were from Taiwan; Brazilian men placed the highest
value on sex, while Thai men placed the lowest on the importance of sex.
Other findings focused on related but distinct sexual issues have also been
presented by colleagues of Laumann. Key points made by Laumann and asso-
ciates are summarized collectively (Laumann et al., 2006; Pfizer Global Study
of Sexual Behaviors, 2002):
• Women were reported to be much less likely to have age-related sexual

“dysfunction” (Pfizer Global Study of Sexual Attitudes and Behaviors ter-
minology) than men whose erectile dysfunction increases with age.
• Women’s sexual “dysfunction” is related to psychological and social factors.
• Pooled data indicated that 31 percent of women lacked interest in sex, 22
percent were unable to orgasm, 21 percent found sex unpleasurable, 20
percent had trouble lubricating, and 14 percent had pain with sex.
• Only trouble with lubrication had significant age effects for women.
More recently, the Sexual Well Being Global Survey (SWGS) was distributed
in 2006 to 26,032 participants in twenty-six different countries. Participants
ranged in age from 16 to 65. This survey identified patterns in sexual behavior
across men and women of different geocultural backgrounds, as well as across
heterosexual and homosexual participants. However, it should be noted that
90 percent of participants were heterosexual (Wylie, 2009: 41). This study was
also funded by SSL/ Durex, aimed at identifying the sexual behaviors and needs
of a population of potential consumers (2009: 45). Key points are summarized:
• Only 44 percent of participants reported very or extreme satisfaction with

their sexual life. Women reported higher satisfaction with their sex lives
as they aged beyond thirty-four years of age (2009: 41).
• Men reported lower levels of satisfaction as relationship commitment in-
creased (2009: 41).
• Participants from Nigeria, Mexico, India and Poland reported the highest
levels of sexual satisfaction; participants from Japan, France and Hong
Kong reported the lowest (2009: 41).
• Self-identified gay males and lesbians reported the highest engagement in
giving and receiving oral sex (2009: 43).
• Ninety-four percent of bisexual females reported experiences in vaginal
sex compared to 77 percent of homosexual women (2009: 43);
• Agreement that sex is beneficial for one’s health and wellbeing was high-
est in Greece and Brazil (2009: 44).
• Forty-two percent of participants did not feel comfortable sharing their
sexual preferences with a partner; women are less comfortable discussing
their preferences than men (2009: 45).
• While lesbians reported the highest rate of sexual satisfaction, they are
the least likely to share their sexual preferences with a partner (2009: 45).
Turning now to the cross-cultural record, we will examine some of the evi-
dence around the issue of aging and sexuality from the middle years through
later years of the life cycle. Cross-culturally the period of the middle years
is defined as the period in which one is not yet old and defined functionally
as a period when one’s children have reached adulthood (Brown and Kerns,
1985). Although cross-cultural research is limited on this period, Judith K.
Brown and Virginia Kerns’ In Her Prime: A New View of Middle-Aged Women
offers an excellent overview of this subject. Brown and Kerns’ work contains
articles focusing primarily on women. There are unfortunately no “systematic
cross-cultural studies of men in their middle years” (Oswalt, 1986: 161). How-
ever, Stanley Brandes’ Forty: The Age and the Symbol (1987), mentioned earlier,
offers an important cultural analysis of the meaning of forty in industrialized
society. According to Brandes (1987: 85), one of the weaknesses in the adult
lifepsan literature is its focus on universals to the detriment of class, cross-
cultural (author’s addition), and ethnic differences. The perceptions of when
one is aging and at what point transitions and stages are demarcated are largely
cultural constructs overlying a biological continuum of changes. A person’s ap-
pearance, position, stage in rites of passage, and reproductive roles demarcate
one’s “age” in society (Winn and Newton, 1982). Thus, Glascock and Feinman
(1981 in Oswalt, 1986: 165) note that maturity and aging are not clearly iden-
tified by physiological changes, but rather by other transitions in the life course
including changes in occupation and work effort, status of children, passing on
of inheritance, etc.
Preindustrial societies do not show the expected variation in what we
conceive of as the midlife experiences of women. In fact, “[t]he changes in
a woman’s life brought about by the onset of middle age” appear to be some-
what positive in nonindustrialized societies (Brown and Kerns, 1985: 2). Three
changes accompany transition into the middle years: restrictions may be lifted,
authority over certain younger relatives may be expected, and women may
become eligible for special non-domestic status (Brown and Kerns, 1985: 2–3).
When women undergo menopause in societies in which menstruation is re-
garded as polluting or taboo, the post-menopausal woman may gain a great
deal more freedom of movement and flexibility in interaction. For example,
they may be free to talk with non-kin males and act in more indelicate and
indecorous ways in societies in which propriety in young women is demanded
(Brown and Kerns, 1985: 3).
Richard Lee (1985: 23–35) reports that Ju/wasi (formerly known as the
!Kung) women between the ages of twenty to forty years old were required to
project a non-sexual image of “shy sweetness.” After age forty, Ju/wasi women
are given much more sexual freedom. An older woman may have an affair with
a young man that may be common knowledge among her cohorts or she may
engage in open sexual joking with men (if over about fifty years old). Women’s
status among the Ju/wasi, which is high to begin with, becomes increasingly
higher as they age so they have greater influence in arranging marriages, par-
ticipating in gift exchanges, and acting in the role of kinship expert.
Cross-culturally, older women may be given the opportunity to be more
influential and exert more authority, including increased access to the labor of
children and their spouses, as well as a more managerial role in food getting
and distribution activities. Control over the distribution of food is one way
that informal power of older women is expressed. Finally, aging may provide
women access to extra domestic positions such as that of shaman, holy or
sacred roles, ceremonial planner, and midwife, among others. The obligations
and taboos around fertility are no longer in effect with menopausal status and
women can command respect, and exert more influence and power. For ex-
ample, by becoming a mother-in-law she can gain status she never had with
maidenhood (Brown and Kerns, 1985: 4–5; Ward, 2006).
The cross-cultural spectrum is broad concerning the issue of sexuality
among older women and men. For example, Vatuk (1985: 147–148) notes in
her research in Western Uttar Parades and Delhi that men and women are
expected to give up sexual relations upon the marriage of the son. In contrast,
for the Ju/wasi, a healthy sexuality is accorded even more leeway for the ag-
ing woman. Lee notes an interesting marriage pattern of older Ju/wasi women
and younger men, a pattern sanctioned negatively in US society (except for
Hollywood movie stars). Approximately 20 percent of all marriages at /Xai/xai
waterhole were between older women and young men. Following divorce or
widowhood it is not uncommon for an older woman to take a younger man as
a spouse (Lee, 1985: 30). It would be interesting to explore further the beliefs
about older women as sexual partners in these kinds of relationships.
Information on sexuality among the elderly cross-culturally is not exten-
sive and it is subject to the same methodological dilemmas of sex research in
general. For example, while human sexuality textbooks may include a cross-
cultural discussion of sexuality in childhood and adolescence, like the subject
of “middle age,” there is little available on the transition to older age. This
is true for the anthropological literature as well, although there is a growing
body of research on this subject, including some cross-cultural correlational
approaches, some comparative approaches, and ethnographic perspectives. In
contrast to the ageism found in the United States regarding sex among older
people, the cross-cultural record shows more acceptance of sex as an activity
and desire that continues throughout the life course as demonstrated in Winn
and Newton’s (1982) cross-cultural correlational study of sexuality and aging
among 106 traditional cultures using the HRAF files. This research identified
common themes and patterns related to aging and sex.
• In 70 percent of the societies (in which data were available) older males
continue to engage in sexual behavior.
• A common ideology in these societies was the expectation that men’s
sexual capabilities were not influenced by age.
• In 84 percent of the societies (in which data were available) older females
continued to have an interest and engage in sexual activities.
• In these societies reports of strong sexual interest by older women were
common.
• In 50 percent of these societies, older women’s sexual expression was re-
lated to their change in reproductive status.
• In 22 percent of the 106 societies older females were permitted to engage
in sexual conversation, sexual humor, and sexual gestures.
• The lessoning of prohibitions in sexual conversation was associated with
older women in 74 percent of the societies.
• Only at very old ages do expectations decrease concerning sexual interest/
activity.
• In only three societies (Taiwan, Northern Greece, and the Philippines)
was disapproval of elderly sex a cultural norm held by young people.
In a study of Greek and Mayan peasant women, Beyene (1989) found none
of the symptoms associated with menopause in industrialized societies. Both
Greek and Mayan women looked forward to it as an end to fertility and re-
ported more interest in sex and improved sexual relations with their husbands.
We can see how biology and gender interact through the cultural system, as
loss of reproductive roles for women often offers them more opportunities.
In this regard Davenport (1977: 115–163) cites some intriguing evidence
from the peasants of Abkhasia who live in the Caucasus region. These peoples
are known for their longevity and continued sexual functioning “long after
70, and even after 100” (1977: 118). The indigenous Abkhasians illustrate the
nexus of biology and culture in the aging process, including reproduction and
sexual expression. The Abkhasians represent an enclaved genetic population,
so there are obviously genetic factors involved in their longevity. Notably, 13
percent of the women continue menstruating after age fifty-five. According
to Davenport (1977: 118), “[o]ldsters continue to work, enjoy their food and
have heterosexual relations in diminishing amounts well beyond ages at which
Western Europeans and North Americans consider such activities to be al-
most impossible.” However, the cultural factors are very important in under-
standing the Abkhasian sexual vigor at advanced ages. These peasants have
no concept of retirement and change at old age. People continue through life
doing everything they have always done, including having sex, but to a lesser
extent. There are no specific negative sanctions concerning sex among the
elderly in contrast to the industrialized societies. The variety of perspectives
regarding sexual interest and activity among middle- to older-aged people con-
tinues to illustrate the richness and diversity of human sexuality throughout
the life cycle and the importance of understanding the influence of culture
upon bio-psychological dimensions of being human.
Summary
1 Sexuality at advanced ages is shaped by numerous biological, psychologi-
cal, and cultural factors.
2 Both men and women experience a physical change that affects sexual
desire, behavior, and expressions to varying degrees.
3 Hormone replacement therapies can regulate changes to women’s bodies
in a number of ways.
4 Cultural ideologies of aging and sexuality vary across cultures.
1 Why is there a social stigma attached to being sexually active at an ad-
vanced age?
2 Why are the physical effects of menopause experienced differently across
cultures?
Suggested Resources
Books
Mattern, S. P. 2019. The Slow Moon Climbs: The Science, History, and Meaning of Meno-
pause. Princeton, NJ: Princeton University Press.
Steinke, D. 2018. Flash Count Diary: Menopause and the Vindication of Natural Life.
S.l.: Picador.
Gross, Z. H. 2000. Seasons of the Heart: Men and Women Talk about Love, Sex, and
Romance after 60. New York: New World Library.
Website
Sexuality in Later Life. ewa. https://www.nia.nih.gov/health/sexuality-later-life.
14 Sexual Identities, Preferences,
and Behaviors
Chapter Overview
1 Defines and describes various sexual identities.
2 Distinguishes between sexual identities and sexual behavior.
3 Defines heterosexism and homophobia.
4 Discusses known sexual behaviors as a continuation of what is found in
the mammalian and primate world.
5 Argues for a greater awareness of all forms of culturally defined sexual
identities.
6 Presents various theories which attempt to explain non-heterosexual
orientation.
7 Discusses sexual identities cross-culturally.
8 Discusses the range of gender role behavior.
Sexual Identities
A discussion of sexual identities and relationships confronts biases and as-
sumptions about sexuality. In many societies presently, including the United
States, heterosexuality is assumed and perceived as a “given.” For those people
who are heterosexual, this seems “normal and natural.” For people who iden-
tify as gay, bisexual, lesbian, or queer, this assumption of heterosexual “nor-
malcy” appears to be biased and based in heterosexist ethnocentrism. As part
of our exploration of human sexuality, we must seriously examine the range of
sexual identities, their possible expressions, and relationship forms.
Some basic definitions are needed. Sexual identity is often conflated with
sexual orientation, which refers to one’s attraction to sexual and romantic
love partners. However, we differentiate between sexual identity and orienta-
tion because sexual identity now refers to one’s own perception of one’s sexual
self, which can differ from one’s sexual orientation. Currently, this identity is
structured in the United States as being most commonly homosexual, bisex-
ual, heterosexual, or queer. However, sexual identities and orientations are
ever-expanding and an increasing number of people are identifying as asexual
or pansexual. A homosexual identity denotes sexual and romantic attraction
toward individuals of one’s own sex or gender. A bisexual identity denotes
Sexual Identities, Preferences, and Behaviors 349
sexual and romantic attraction toward both one’s own and the other sex or
gender, sometimes referred to as ambisexual. A heterosexual identity is sexual
and romantic attraction toward individuals of the other sex or gender. An
asexual identity refers to not being sexually attracted to other people at all,
and a pansexual identity refers to attraction to people regardless of their sex or
gender. A queer identity rejects rigid sexual attraction binaries based on sex-
uality, gender, or both. Relatively non-judgmental terms used to describe each
of these identities include “straight” for male and female heterosexuals, “gay”
for male, and “lesbian” for female homosexuals, particularly for those who are
open or “out” about their identities, and “bisexual” for male and female bi-
sexuals. Similarly, “same-sex” sexual behavior refers to two biological or natal
males or females having sex, but it can also refer to same-gender sexual behav-
ior where sexual partners may share a gender identity (i.e., both identifying as
men or women) but may not share a biological sex (i.e., being physically male
or female). For the sake of eliminating redundancy, we note that same-sex
sexual behavior includes same-gender sexual behavior.
Sexual identity is not synonymous with sexual behavior; these are dis-
crete entities. As with sexual identity, sexual behavior may be homosexual,
bisexual, or heterosexual. Given our culture’s assumptions about heterosexu-
ality, lesbians, gays, and bis may experience confusion and rejection in estab-
lishing their identity. Since the late twentieth century a number of groups
and events have helped people become more comfortable with and accepting
of sexual orientations. These include the Gay Rights Movement and Gay,
Lesbian, Bisexual, Transgender, and Queer Pride Parades (Blackwood and
Wieringa, 1999b).
The mayor of Moscow, Russia, Yuri Luzhkov, tried to ban the first-ever
Gay Pride Day in the city in February 2006. Human Rights Watch, among
other international groups, called on the mayor to allow the parade as
an example of tolerance and acceptance of “universal” human rights
(Human Rights Watch, 2006).
A person’s sexual identity and behavior may or may not be consonant. This
can occur for example, when one’s sexual partner of choice is not available,
as in sex-segregated institutionalized populations such as prisons or all-boys’
or all-girls’ schools, or where one’s choice is culturally proscribed. This latter
situation frequently occurs in the United States, which is overtly homophobic.
Homophobia is the fear, prejudice, and negative acting-out behavior toward
people who self-identify or are believed to have a homosexual orientation. Re-
searchers such as Boswell (1980), Greenberg (1988), and Johansson, Dynes,
and Lauritsense (1981/1985) believe that the presence of homophobia in most
twentieth- and twenty-first-century societies is a continuation of practices and
350 Sexual Identities, Preferences, and Behaviors
beliefs derived from Judaism and the Old and New Testaments. These beliefs
have been perpetuated by Christianity and the Catholic Church since the
Middle Ages.
In part, these homophobic positions are a reaction to the non-reproductive
aspects of same-sex sexual relations and their accompanying sex-for-pleasure
aspects. The repercussions of this prejudice have been felt politically, econom-
ically, socially, and religiously to the present. In a homophobic society such as
ours, for example, a same-sex sexual orientation may be hidden. The behav-
ior may be heterosexual and those involved pass (i.e., appear to be straight
in public). Alternatively, a same-sex orientation may be expressed openly in
communities where it can find support and relative degrees of acceptance and
safety. For example, “gay communities” such as Key West in Florida, West
Hollywood in Los Angeles, the Castro in San Francisco, or the Village in New
York (Blumenfeld and Raymond, 1989; Kelly, 1988; Kirk and Madsen, 1989).
Causes of Sexual Orientation

The cause of anyone’s sexual identity or orientation is unknown. As noted
above, we differentiate “identity” from “orientation,” although much of the
past literature focuses on the latter term. For the following discussion, we will
defer to the use of orientation to reflect historical accuracy. Over the past
hundred years in industrialized cultures, volumes have been written in the pro-
fessional and lay literature to explain the roots of one’s sexual orientation, par-
ticularly if it is homosexual or bisexual (Bailey and Pillard, 1991; Hamer and
Copeland, 1994; Rust, 1999). Heterosexuality is assumed to be “normal” and
therefore needs no causal explanation (Allgeier and Allgeier, 1991). If we ex-
amine sexual behavior and orientation from cross-cultural, evolutionary, and
interspecies perspectives, we find a wide variety of sexual expressions (Vance
as cited in SOLGAN, 1992).
Anthropologists conduct research about sexual orientations. Ford and
Beach (1951) and others document a range of sexual expression in the mam-
malian and non-human primate world that includes hetero-, bi-, and homo-
sexual behavior (Ford and Beach, 1951; Herdt, 1981, 1982, 1984a, 1984b, 2006;
Weinrich, 1987). Williams (1986), Gregersen (1983, 1992), Marshall and Suggs
(1971), and Frayser (1985) have documented the widespread nature of homo-
sexual, bisexual, and heterosexual orientations and behavior cross-culturally
and through time (Vance cited in Roscoe, 1998; SOLGAN, 1992).
Ford and Beach’s research documents at least 76 out of 141 societies where
homosexuality is acknowledged and receives varying degrees of acceptance
for those who identify or behave as such (1951). In addition, Williams’ and
Roscoe’s research clearly shows that third-sex, two spirit, or other forms of
sexual identities are well integrated into some cultures worldwide (Roscoe,
1998; Williams, 1986). These identities do not translate smoothly into in-
dustrialized societies, such as the US worldview, due to homophobia, hetero-
sexism, and cognitive rigidity in the formation of sexual identity boundaries.
These identities, such as those discussed in Chapter 15, have meaningful, re-
spected roles in their own cultures.
A variety of Melanesian groups provide a wealth of data that contradict our
industrialized notions of sexual identity, orientation, and behavior. In Herdt’s
Ritualized Homosexuality in Melanesia (1984a) and his most recent work on
the Sambia (2006), ritualized homosexual behavior, what he refers to as “boy-
inseminating rites,” is examined from spiritual, social, male identity, and gen-
der-relations perspectives (2006: xv). Our ideas about sexual orientation and
behavior may be culture-bound when compared with sexual behavior that is
perceived to be related more to concepts of spirituality, generativity (perpetu-
ating oneself and the group), adult male-female systems of balance and order
in the world, and the cycle of life and death. The Sambia from New Guinea
will once again be used as an example of an alternative view on sexuality and
male-female relations.
Data about the Sambia people in New Guinea reveal a radically different
approach to homosexuality than found in our culture. Our conceptualization
of homosexuality does not neatly apply to Sambian sexual practices. The hor-
ticultural Sambia live in an impacted habitat of perceived limited resources
of which ejaculate is also seen as a scarce, precious commodity. As with other
“spermatic economies” (Barker-Benfield, 1975), semen (more accurately ejac-
ulate), a vital life fluid, is believed to exist in finite quantities. Since semen
is seen as life enhancing and a source of male strength, pre-adolescent and
adolescent boys engage in fellatio with other older males to nourish and build
their strength and vitality. Male-to-male fellatio is seen as essential for healthy
male psychosexual and physical development and preparation for heterosexual
marriage and procreation (Herdt, 1984, 1993). Women, however, for a number
of reasons, are seen as a potential drain in this vital life essence. Therefore,
as we discussed in Chapter 8, male and female sexual contact, particularly p-v
intercourse, is carefully controlled and channeled to protect the male from
“losing” his energy (jerungda) and to ensure the healthy development of the
fetus (Herdt, 1984, 1993). Herdt’s most recent book on the Sambia indicates
changes in these practices. Due to the influence of culture contact and change,
Sambians of the current generation are starting to adopt sexual and relation-
ship patterns that more closely resemble those of industrialized societies than
those of their parents and grandparents (Herdt, 2006).
As with research done on sexual orientation in the United States, there is
less cross-cultural research on bisexuality and lesbianism (Logie et al., 2012: 1;
Dworkin, 2005: 6; Rust, 1999; SOLGAN, 1992: 9–10). This may be due to sev-
eral reasons. First, male researchers have less direct access to women and their
daily, intimate lives cross-culturally. The potential for sexual behavior that
could disrupt indigenous patrilineal and bilineal descent systems makes both
sexual and non-sexual access to females by male researchers taboo. Second,
in industrialized societies, there is more interest in male homosexuality than
either female homosexuality or bisexuality. Third, gender role boundaries are
more rigid for males than for females in many societies. For example, the same
behavior engaged in by two men as by two women in our culture is more likely
to be interpreted as “homosexual” for the men, but not for the women. Two men
walking arm in arm solicit different labels and responses in this culture than two
women walking arm in arm. A similar kind of tunnel vision may be operative
in examining female homosexuality cross-culturally. Research attempts to fill
in this gap (Blackwood, 1986; Blackwood and Wieringa, 1999a; Kendall, 1999).
Blackwood’s and Wieringa’s edited book explores female same-sex relationships
historically and cross-culturally. Their book challenges ideas of female sexual
passivity and gender conformity (Blackwood and Wieringa, 1999a).
Minimally, the nature of our sexual orientation and behavior is a complex
interaction of a number of socio-cultural, psychological, and biological factors.
Our sexual behavior is probably one of the more plastic or malleable behaviors
we engage in as a species. Numerous theories and arguments proposed by re-
searchers suggest that biological, genetic, in utero, psychoanalytic, and socio/
environmental elements are involved in forming sexual orientations and be-
haviors that are not heterosexual. In the United States, we have a difficult time
accepting ourselves as sexual beings and that a variety of sexual orientations
and behaviors are part of human sexuality. The only difference in other- and
same-sex sexual behavior is one of reproductive success: other-sex sexual be-
havior may lead to production of viable offspring; same-sex behavior does not.
However, as discussed in Chapter 3, not all other-sex sexual behavior is repro-
ductive. Deep kissing (referred to as “French Kissing”), masturbation, oral gen-
ital contact, anal penetration, and effective birth control with penile-vaginal
intercourse do not make babies. At various times in this and other cultures,
all these behaviors have been seen as “unnatural,” “abnormal,” or “sinful” in
certain religious contexts (Bullough, 1976).
Biological theories may be used to explain sexual orientation examine hor-
mone levels pre- and postnatally, and differences in the size of brain structures
as well as the sexual differentiation process in utero (e.g., Gladue, Green, and
Hellman, 1984; Green, 1987; Kelly, 1988; LeVay, 1991; Money, 1988; SOLGAN,
1992). Research from the 90s offers a genetic basis for male homosexuality
(Bailey and Pillard, 1991; Hamer and Copeland, 1994). All of these theories
attempt to explain the cause of homosexual orientation, particularly for men.
These theories speculate on delays or differences in release of androgens, LH,
relative levels of estrogen and testosterone pre- and postnatally, genetic pre-
dispositions carried on the X chromosome, or the size of the hypothalamus as
predispositions to a homosexual orientation. These theories gain some level
of support from the self-descriptions of gay men who believed from an early
age they were more comfortable with and more attracted to members of their
own sex. They are biased in that they only look at male homosexuality, not
lesbianism, and they do not explore sexual orientations as social phenomena
(see also Vance’s comments in SOLGAN, 1992).
Psychoanalytic theories about sexuality often are misinterpretations of Freud’s
view that we are essentially bisexual in nature, and that society suppressed and
channeled homosexuality (Freud, 1920a and 1959 [1929]; Kelly, 1988). These
theories frequently posit a bi- or homosexual orientation as “deviant.” It is de-
picted as “arrested psychosexual development” or viewed as a function of a poor
parent-child relationship. The American Psychiatric Association (APA), after
intensive lobbying efforts by members of the gay communities, removed ho-
mosexuality from its list of “personality-sexual disorders” in 1973. The formal
removal of this category from the Diagnostic and Statistical Manual of Mental
Disorders (DSM-III), however, does not necessarily change the beliefs of mem-
bers of both the medical and lay communities who do not accept the behavior
(American Psychiatric Association, 1973; Bjorklund and Bjorklund, 1988).
Discussions about the origins of sexual orientation and the sex of one’s
sexual and romantic love partners are emotionally and legally charged
in the United States. The Supreme Court decided in 2003 that adult,
consensual, same-sex behavior in the privacy of one’s home was not a
crime. It overturned a case of two men who were arrested for engaging
in sex at home.
Socio-psychological, environmental, and learned behavior theories about

sexual orientations also focus on homosexuality, thereby assuming hetero-
sexuality as the norm. They primarily discuss gay men, not lesbians or bisex-
uals. This kind of bias implies a negative difference if one is anything except
straight in behavior and orientation. These culture-specific theories relate
sexual orientation and behavior to childhood and adolescent sexual experi-
ence, role models, and learned pleasurable and unpleasant sexual activities
(Kelly, 1988; Rust, 1999).
Although acknowledging and recognizing these explanations about sexual
orientation, this chapter posits that human sexuality is part of what makes us
human, that it is an interaction of biological and learned experiences whose
boundaries are currently unknown to us. Our sexual orientation is part of our
socio-psychological and biological makeup. Increasingly, we will probably learn
that orientation itself has a biological component (Money, 1988; Small, 1993).
Yet each society channels sexual behavior into culturally defined appropriate
outlets. The following sections examine straight, gay, bi, and lesbian lifestyles
as functions of their cultural milieus and as dimensions of the richness, adapt-
ability, and diversity of the human sexual repertoire.
Bisexuality
There is increasing research on bisexuality, but less than exists for gays and
straights (Klein, 1978; Paul, 1984; Rust, 1999; Tielman, Carballo, and Hen-
driks, 1991). A bisexual orientation is a romantic and sexual attraction toward
both men and women. Both men and women can self-identify as bisexual.
Bisexuals may choose only same-sex partners, partners of the other sex only,
or of both sexes and genders. (Bisexuality is not synonymous with group sex
where people have multiple partners concurrently.) The following statements
come from one of your author’s files (Whelehan):
I am a self-identified [male] bisexual who generally acts out on my attrac-

tion to men. However, every once in a there is a woman to whom I’m
strongly emotionally and sexually attracted and I decide to pursue that
interest.
I believe everyone is pansexual [open to a variety of sexual experiences].
I am attracted to both men and women and don’t care about society’s
labels. (Female)
It’s natural. It’s an extension and expression of the love I feel for some
of the people in my life, both men and women. (Female)
Of all the sexual orientations discussed, bisexuality appears to receive the least
acceptance, even though bisexual behavior has been estimated to be the high-
est. However, estimates of bisexuality are contradictory in current research.
As of 2011, one study indicates that among adults who identify as lesbian, gay,
or bisexual, there are slightly more bisexual-identifying people (1.8 percent)
than lesbian or gay individuals (1.7 percent) (Gates, 2011: 3). The National
Health Interview Survey performed by the CDC in 2013 indicated 96.6 per-
cent of American adults identified as heterosexual, 1.6 percent identified as
lesbian or gay, and 0.7 percent identified as bisexual. The remaining 1.1 per-
cent said they identified as something else, didn’t know, or refused to answer
(Ward et al., 2014: 5).
Bisexuals, on average, tend to be closeted, and are often most comfortable
with other bisexuals since both the straight and homosexual communities have
difficulty understanding and accepting them (Mclean, 2007: 164; Maliepaard,
2018: 154). Compared to heterosexual populations, as well as other LGBTQ
groups, bisexual people have higher rates of suicidal behavior and substance
abuse (Pompili, 2014: 1909). Gays, lesbians, and straight people often pressure
bisexuals to choose a straight, or gay, or lesbian behavior and identity, possi-
bly so that the non-bisexuals are more comfortable. Straight people can see
bisexuals as “playing a game,” “going through a stage,” as being indecisive, or
as being homosexual; this exclusive, discriminatory behavior toward bisexual
people (by heterosexual or homosexual groups) is known as “biphobia” (Barker
et al., 2012: 21). Since some closeted gay men and lesbians do engage in hetero-
sexual relations, this behavior further reinforces misperceptions about bisexu-
als. In addition, since this culture only accepts a heterosexual orientation and
behavior as “normal,” people can be confused, trying to sort out their feelings
and behavior. They may experiment sexually with members of their own and
the other sex as part of psychosexual growth (Klein, 1978; Rust, 1999). One
of the more unfortunate aspects of bisexuality, which is also shared with ho-
mosexuality, is the hiding and passing some bisexuals engage in because of
non-acceptance by the larger society. As Paul posits, bisexuality is part of the
range of human sexual behavior (1984). It is probably the most inclusive of the
orientations and one that can directly contribute to reproductive success.
Homosexuality
A homosexual orientation is the romantic and sexual attraction to mem-
bers of one’s own sex or gender, frequently called gay, when the attraction
is openly acknowledged between men, and lesbian when it occurs between
women. Kinsey et al. estimated that at least 10 percent of the US population
is exclusively homosexual (1948). On Kinsey’s scale, which is a measure of
behavior, not orientation, bisexuals are a two to five clustering in the three
to four range (Kinsey et al., 1948, 1953; see Table 14.1). In the United States,
Gates (2011: 1) found that 8.2 percent of Americans reported same-sex sexual
behavior and 11 percent acknowledge same-sex sexual attraction. Current re-
search in the United States indicates that the number of US adults identifying
as LGBTQIA has increased from 3.5 percent in 2012 to 4.5 percent in 2017;
this increase has been driven almost entirely by millennials, Hispanics, and
Asian groups have seen the largest increase in reported homosexuality. Re-
ported homosexuality in these groups increased from 5.8 percent in 2012 to
8.1 percent in 2017 (Newport, 2018). Gates (2011: 1) estimates that roughly 19
million American adults have engaged in same sex sexual activity, and around
25.6 million Americans acknowledge some level of same-sex sexual attraction.
Kinsey’s figure may be under-reported since the scale does not clearly distin-
guish between orientation and behavior; research from other sources includ-
ing cross-cultural material would support at least that percentage (Bell and
Weinberg, 1978; Ford and Beach, 1951; Kirk and Madsen, 1989; Walter, 1990).
Current research supports this claim: a recent survey of US high school stu-
dents found that of those who engaged in same-sex behavior, most identified as
heterosexual. Defining sexual orientation in research practice is difficult, and
future studies should include various dimensions of sexual identity, including
behavior, sexual and romantic attractions, to accurately assess homosexuality
(Mustanski et al., 2014: 241). In terms of gender differences, gay men tend
to reach milestones of coming out to family members or friends earlier than
women (Pew Research Center, 2013). About 5.1 percent of women identified
as lesbian, gay, bisexual, transgender, queer, intersex, or asexual in 2017, as
opposed to 3.9 percent of men (Newport, 2018).
Research published in 1994 stating that homosexuals comprise only 2 per-
cent of the population is questionable since orientation and behavior were
confused, and criteria by one of the researchers included that his subjects were
out to their family, friends, and the researcher (Michael et al., 1994).
As part of sexual culture change since the 1960s, many gays and lesbians
have become more open and more desirous of formal social recognition for
themselves and their relationships (Bell and Weinberg, 1978; Kirk and Madsen,
1989). According to a 2017 study, 10.2 percent of LGBT adults in the United
States were married to a same-sex spouse, and 13.1 percent of LGBT individu-
als were married to an opposite-sex spouse (Jones, 2019). Nearly two-thirds of
married same-sex couples are lesbians and only about one-third are gay men.
Gays and lesbians want to live and work openly with their partners, be part
of extended kin groups as couples, and receive comparable economic and so-
cial recognition and acceptance as do straight couples. Nowhere is this more
obvious than in the controversies surrounding gay marriages. Massachusetts
was the first state to legalize same-sex marriages in 2003, followed by Con-
necticut in 2008 and Iowa, Vermont, New Hampshire, and Washington, D.C.
in 2009. San Francisco married same-sex couples in 2004, but those marriages
were contested by the governor and the state (Marshall, 2004; “Opinion: US
Requirement that AIDS Group Sign Pledge against Sex Work,” 2005). Sev-
eral states passed legislation either banning same-sex marriages or refusing to
recognize those marriages performed in Massachusetts. This issue is so conten-
tious that President George W. Bush proposed a constitutional amendment to
ban same-sex marriages. That the federal government would seek to formally
and legally deny entire groups of people rights that are granted to others is
further evidence of our discomfort with sexual orientations and with sexuality
that is not potentially reproductive (Buchanan, 2005a).
Following President Bush’s administration, former President Barack Obama
announced in 2011 the Department of Justice would no longer recognize the
Defense of Marriage Act, in which marriages were only recognized if they were
between a man and woman (Office of the Press Secretary, 2016). In a landmark
ruling on June 26th, 2015, the Supreme Court voted to legalize gay marriage in
all fifty states. Groups of same-sex couples sued state agencies in Ohio, Michigan,
Kentucky, and Tennessee to challenge the rights of states to ban same-sex mar-
riage and to recognize legal same-sex marriages that occurred elsewhere (Oyez,
2015). The following excerpt from the decision embodies a momentous moment
in long political battle for LGBTQ rights in the United States:
As some of the petitioners in these cases demonstrate, marriage embod-

ies a love that may endure even past death. It would misrepresent these
men and women to say they disrespect the idea of marriage. Their plea
is that they do respect it, respect it so deeply that they seek to find its
fulfillment for themselves. Their hope is not to be condemned to live in
loneliness, excluded from one of civilization’s oldest institutions. They
ask for equal dignity in the eyes of the law. The Constitution grants
them that right.
(Justice Anthony Kennedy, Obergefell v. Hodges, 2015: 28)
As of 2018, Washington D.C. reported the highest rate of same-sex marriages

in the United States at 4.17 percent of all married couples, followed by Mas-
sachusetts and Vermont at 0.99 percent (Fisher, Gee, and Looney, 2018: 14).
San Francisco, California is the city with the largest percentage of same-sex
marriages at 1.52 percent; Provo, Utah has the lowest percentage of same-sex
marriages at 0.13 percent (Fisher, Gee, and Looney, 2018: 14).
While LGBT rights tend to be in the spotlight in the United States, the
Netherlands has long supported gay marriage since 2001. Approximately thirty
countries support gay marriage, most of which are in Europe and the Americas
(Pew Research Center, 2019). As opinions on gay marriage vary state to state,
countries also enact a variety of different policies about gay marriage that have
changed in recent times. In the last year alone, four countries legalized gay
marriage, including Ireland, Taiwan, Austria, and Ecuador. Australia, Malta,
and Germany legalized gay marriage in 2017 (Pew Research Center, 2019).
As people with varying degrees of formal acceptance in our culture, gays
and lesbians have also established flexible, adaptable gender roles and divisions
of labor relative to economics, household management, and social behavior.
Straight couples struggling to redefine gender role expectations and behaviors
may be able to use the flexibility of stable gay and lesbian relationships as models
(Blumstein and Schwartz, 1983; Bryant and Demian, 1990; Kirk and Madsen,
1989). As a survey indicates, a large number of homosexual couples live in stable,
satisfying, long-term relationships. They have worked out economic, social, and
sexual issues. As with many heterosexual couples, homosexual couples can have
similar problems with communication (Bryant and Demian, 1990).
The Stonewall riots in June 1969 were the formal marker of the Gay Rights
movement. Customers of the Stonewall, a bar in the Village in New York City,
refused to be arrested or evicted from the bar when police arrived on a sweep,
and rioted instead against police arrests of patrons solely because they were in
a gay bar (Kelly, 1988; Kirk and Madsen, 1989). Gays and lesbians as a group
in this culture have become more organized and vocal in demanding equal
legal, economic, and social treatment in their personal and professional lives.
This involves an end to discrimination and harassment relative to service in
the military (another heated controversy), in housing, employment, medical
care, and in their interpersonal relationships (“Opinion: US Requirement that
AIDS Group Signs Pledge against Sex Work,” 2005). It encompasses respect
for them as individuals and the range of roles they fulfill in society, including
their roles as parents, friends, and family members.
Homosexual adolescents in the United States tend to live in non-accepting,
potentially hostile, and rejecting environments if they self-identify or are per-
ceived to be homosexual. Homosexual adolescents in this culture have issues
to resolve as well. Not only do they share common adolescent concerns about
appearance, peer acceptability, sexual and drug decision making, and about
communicating with adult authority figures, they also need to recognize and
accept their sexual orientation. In a society that places much emphasis on
conformity and normalcy, bringing a same-sex or same gender date to a public
event, not concealing pronouns when referring to boyfriends and girlfriends,
and not wanting to appear “queer” or “faggy” can create considerable stress
for a gay or lesbian adolescent. Our homosexual youths have a relatively high
suicide attempt rate (Whitaker, 1990). Parental and other adult support, val-
idation of the worth of the person, location of support, and homosexual ado-
lescent groups can help gay and lesbian youths accept and flourish as who they
are.1 One benefit of gay liberation is that homosexual youths are beginning to
have their own support groups and organizations. These are “safe” places to
be themselves and interact (Sullivan, 1998). Given this support, homosexual
youths do accept themselves and can develop into well-adjusted, functioning
adults (Boxer and Cohler, 1989).
During his first administration, President Clinton endorsed a “Don’t

Ask, Don’t Tell” policy concerning sexual orientation in the military.
Under this policy, people could not be asked about their sexual orienta-
tion in the military, but they also were not permitted to be open about
either their orientation or behavior unless it was heterosexual. In 2011,
President Barack Obama repealed this policy, legally permitting LGBTQ
people to serve in the military without having to hide their sexual ori-
entation. The repeal also promised increased access to LGBTQ-related
healthcare, although this aspect of the repeal has come under fire re-
cently under the current administration under President Trump. In 2017,
President Trump announced that transgender individuals would no lon-
ger be able to serve in the military due to so-called medical costs associ-
ated with transgender health care. While this policy change was denied
by the Department of Justice, Trump released a new policy in 2018,
banning transgender individuals who have a history of gender dysphoria
from serving in the military except under certain limited circumstances.
This policy went into effect in 2019 and remains a contentious point of
political debate regarding LGBTQ rights.
Lesbianism
Research on lesbian, gay, and transgender individuals’ health has increased
compared to research about bisexual individuals. However, much of LGBT
research is focused on sexually transmitted diseases, which typically recruits
participants who are gay men (Boehmer, 2002: 1128). The HIV/AIDs crisis of
the 1980s in particular excluded women who have sex with women from most
research (Logie et al., 2012: 1; Dworkin, 2005: 6). Although there is a growing
awareness and increasing body of literature in this culture on lesbianism (cf.
Blumenfeld and Raymond, 1989) and cross-cultural documentation of lesbian
relationships (Blackwood, 1986; Blackwood and Wieringa, 1999a), lesbian re-
lationships and life-styles, like bisexual relationships, are historically discussed
less than those for gay men (SOLGAN, 1992). There may be several reasons
for this bias. Lesbian relationships tend to be less formalized and ritualized.
Females in general have greater flexibility to form female-female bonds and be
demonstrative than do males. Thus, lesbians may “pass” intentionally or un-
intentionally more readily than gays or bisexual men. Third, female sexuality
is structured differently from male sexuality. Unless it threatens known pater-
nity, female sexuality is not seen as having the same kind of force, power, vis-
ibility and possible threat as does male sexuality, particularly in industrialized
societies, which generate most of the researchers and research (Blackwood,
1986; Blumenfeld and Raymond, 1989; Kelly, 1988). Evelyn Blackwood and
Saskia E. Wieringa’s edited work on lesbian sexuality cross-culturally chal-
lenges European models of lesbians and research on women who identify as
lesbian. They see the lack of data on lesbians as due to: “problems in collection
and interpretation as well as to the silence of Western observers and scholars
on the topic of female sexuality” (Blackwood and Wieringa, 1999a: 39).
Cross-culturally and in the United States, lesbian relationships manifest a
great deal of flexibility and tend to emphasize the interpersonal dimensions of
the interactions (Blumenfeld and Raymond, 1989; Blumstein and Schwartz,
1983; Bryant and Demian, 1990; Herdt, 1984b; Weil, 1990). As with gays,
lesbians are parents who have well-adjusted children, friends, colleagues, and
neighbors. Lesbians overall show no greater psychological problems than do
straight women. In fact, research indicates that homosexuals who accept and
are comfortable with each other have high levels of self-esteem and may have
more stable relationships than the average heterosexual (Blumenfeld and
Raymond, 1989; Blumstein and Schwartz, 1983; Bryant and Demian, 1990;
Herdt, 1984b; Kirk and Madsen, 1989; Weil, 1990). Lesbians and gays may
have had to learn to be psychologically strong to confront the discrimination
they experience from the larger culture in a healthy way.
Heterosexuality
The degree of heterosexual bias in our culture is illustrated by the number of
heterosexual inventories that exist and the assumption that people are hetero-
sexual in both orientation and behavior. Although there have been some in-
roads made in the area of popular culture with television shows such as Queer
Eye for the Straight Guy, Will and Grace, Queer as Folk, and Transparent, as
well as movies such as Priscilla, Queen of the Desert, The Birdcage, Brokeback
Mountain, Carol, and Moonlight, we continue to have trouble recognizing dif-
ferent lifestyles in our own and other cultures. As Vance has stated, our con-
cept of homosexuality is “only found in modern, Western societies” (SOLGAN,
1992: 9). For example, in some books on orientations, behaviors, and genders
cross-culturally, it is difficult to find vocabulary to label and describe the man-
ly-hearted women among Plains Indians, the nadle among the Navaho, and
other forms of identity and behavior that is common, accepted, and valued
elsewhere (Roscoe, 1998; Williams, 1986).
In the post-WWII era in the United States, the ideal adult sexual standard
was that of a heterosexual, middle-class, monogamously married couple with
a minimum of two children—a boy and girl, in that order of preference. The
couple owned their own home where the woman worked full time without
monetary compensation and the man worked outside the home with paid full-
time employment (Blumstein and Schwarz, 1983; Frayser, 1985; Kinsey et al.,
1948, 1953). This ideal persisted until the Sexual Revolution of the mid-1960s
(discussed in Chapter 15) when these values and behaviors that were labeled
“traditional” were behaviorally challenged and questioned. During the Sex-
ual Revolution many people’s behaviors, but not necessarily their attitudes
changed. The changes in behavior but not attitudes led some researchers to
question whether there was a sexual revolution (Kelly, 1988; Weil, 1990).
Behavioral changes include more open sexuality outside of marriage, cohab-
itation, open marriage (O’Neill and O’Neill, 1972), and higher divorce rates as
well as the continuation of the traditional marriage (Blumstein and Schwartz,
1983). In the twenty-first century, there are numerous relationship patterns:
• It is now more common to cohabit than marry: 59 percent of adults ages

18–44 have lived with an unmarried partner, while 50 percent have never
been married (Pew Research Center, 2019).
• The current divorce rate is 2.9 per 1,000 population (CDC, 2017), al-
though the divorce rate has risen for women without a college education
and fallen for those with a college education (Cherlin, 2005: 38).
• Approximately one in five children live in a single parent household with
a female parent; nearly half of all black children live with a single female
parent (Pew Research Center, 2018).
• Serial monogamy is the dominant relationship pattern (Blumstein and
Schwartz, 1983; US Bureau of Labor Statistics, 1985; US Census Bureau,
1980, 1990, 2000; Weil, 1990); an estimated 4–5 percent of Americans en-
gage in consensually non-monogamous relationships (Rubin et al., 2014: 3).
There was a slight drop in the divorce rate in the 1980s. This was attributed to:
the fear of AIDS and other sexually transmitted diseases; the economic ben-
efits of staying married contrasted with the economic hardship of separation,
divorce, single parenting, and child support; and the realization that being an
older single adult can lead to socio-sexual isolation (Weil, 1990). Ironically, the
decrease in divorce is not attributable presently to couples’ love for each other
or their desire to be together as a socio-psychological unit.
Although heterosexual marriage continues as a statistical norm, 45.2
percent of all US residents age eighteen and older choose to be single (US
Census Bureau, 2017). People are marrying slightly older—the median age of
women when they marry is twenty-eight, and men when they’re thirty years
old (US Census Bureau, 2019). These variations can be attributed to a variety
of factors. They include greater educational, career, and economic opportunity
and flexibility for both men and women; behavioral changes in gender-role ex-
pression and expectations, and greater materialism. There is also a generation
of children of divorced parents who are now adults, and who may be postpon-
ing marital commitment based on their experiences as children in custodial
situations.
Interestingly, when men and women in this culture are asked how sexuality
fits into their life and relationships, there tends to be both consistency and
diversity through time between them regardless of their sexual orientation.
Women, both lesbian and straight, tend to see sexuality as part of and an
expression of the relationship. Men, both gay and straight, tend to see sex-
uality as a physical pleasure, and a release of sexual tension (Blumstein and
Schwartz, 1983; Critchlow-Leigh, 1990; Hite, 1976, 1981, 1987; Kinsey et al.,
1948, 1953; Shilts, 1987). Both men and women are orgasmic, enjoy sexual
release, and enjoy sex in the context of a love relationship regardless of orien-
tation (Blumenfeld and Raymond, 1989; Blumstein and Schwartz, 1983; Bry-
ant and Demian, 1990; Critchlow-Leigh, 1990; Farrell, 1986; Goldberg, 1984;
Hite, 1976, 1981, 1987).
Sexual Orientations Cross-Culturally

As with discussions of gender in Chapter 12, explorations of sexual orien-
tations are culture-specific. Industrialized societal ideas and terms for sexual
orientations may have little meaning cross-culturally, either for ethnic sub-
cultures in industrialized societies or elsewhere (Buhgra, 1997). This does not
mean that sexual behavior other than heterosexuality does not exist or that
it is not recognized, but that the structure and expression of non-heterosexual
relationships and behavior are highly variable. Same-sex sexual behavior is
historically and culturally prevalent. It, as with many sexual behaviors, has
been impacted by culture contact with Euro-Americans and has significantly
changed as a result of that contact. For example, same-sex sexual behavior for
both men and women is well documented in pre-contact sub-Saharan Africa,
China, India, Japan, and Thailand (AFROL, 2003; Blackwood and Wieringa,
1999a; Kahn, 2001; Nanda, 1999; Ruan, 1991; Ruan and Bullough, 1992a;
Ruan and Tsai, 1988; Wikan, 2000). Indigenously, this behavior was integrated
into the culture, and generally was less stigmatized than it is currently. Same-
sex behavior was accepted in China, Japan, India, and among the Lesotho
in sub-Saharan Africa. Acceptance of same-sex relationships cross-culturally
relates to larger societal views about maleness and femaleness, balance and
harmony, sexuality and spirituality, as well as the nature of heterosexual rela-
tionships and reproduction (Bullough, 1976, Kahn, 2001; Nanda, 2000; Ruan
and Bullough, 1992a; Whitam et al., 1998). People in these societies, however,
generally did not develop an identity based on these behaviors and relation-
ships; that is a uniquely industrial and recent phenomenon.
Culture contact and colonization changed indigenous sexual practices and
views as it did other aspects of society (AFROL, 2003; Kahn, 2001; Ruan
and Bullough, 1992; Whitam et al., 1998). The widespread prevalence of ho-
mophobia currently is largely a function of culture change. Globally, most
societies are overtly homophobic as indicated by formal social and legal sanc-
tions. Globally, it is estimated that out of 103 countries, approximately 53 of
them enact exclusive policies toward LGBTQ people serving in the military.
Seventy-two governments around the world still criminalize same-sex sex. Of
those seventy-two governments, the death penalty is a possible punishment
for twelve. At least six countries (Iran, Northern Nigeria, Saudi Arabia, So-
malia, Sudan, and Yemen), actively implement anti-LGBTQ laws, while oth-
ers simply hold a legal possibility of discriminating against LGBTQ people
(Afghanistan, Mauritania, Pakistan, Qatar, and UAE). Fifteen governments
criminalize transgender individuals/gender non-conformity with varying se-
verity: Nigeria punishes with death by stoning, whereas Zambia punishes with
life imprisonment (Human Dignity Trust, 2019). Most recently, Russia passed
a federal law illegalizing homosexuality as well as the distribution of “homo-
sexual propaganda” to minors in 2013 (ILGA-Europe, 2015: 134). Despite this,
same-sex or same gender relationships exist and there are international orga-
nizations that support them (IGLA-Europe, 2015; Blackwood and Wieringa,
1999a; Carillo, 1999; Whitam et al., 1998).
There are a variety of ways cultures respond to same-sex sexual behavior.
Within non-assimilated Latino subcultures in the United States and in Latin
America, for example, men who take the insertive role in sex retain their iden-
tity as male and heterosexual, regardless of their sexual behavior or the sex of
their partners (Aggleton, 1994; Halperin, 1994, 1999; Parker and Aggleton,
1997). In these cultures, if the man is sexually discreet, his family is relatively
accepting of him. Closeted African American men who engage in same-sex
sex, referred to as being “on the down low,” face potential rejection from fam-
ilies, their church, and the community, and thus may keep this part of their
lives secret (Clay, 2002). In Asian-American communities, “maintaining face”
is important. “Face” is a public behavior that honors the family and its values.
Therefore, same-sex behavior may be hidden among this group as well. Gen-
erally, the less acculturated the group, the more people’s behaviors are hidden
(Choi et al., 1995). Outside the United States, stigmatization and sanctions
can make it difficult or dangerous for people in same-sex relationships to be
“out.” Since the late twentieth century, movements in China and India are
trying to create more accepting conditions for same-sex relationships.
Summary
1 There are several forms of sexual identities and sexual orientation—
homosexual (gay or lesbian), bisexual, and heterosexual.
2 Sexual orientation is not synonymous with sexual behavior.
3 We do not know what causes anyone’s sexual orientation. However, het-
erosexuality is assumed to be normative in the United States, and thus is
unexplained. In contrast, homosexuality and bisexuality often are seen as
stigmatized or variant orientations and have been explained by a number
of theories.
4 There is a wide continuum of sexual behaviors in the animal and human
worlds.
5 Heterosexism and homophobia are widespread in the United States; defi-
nitions and expressions of sexual orientations vary by society and are in-
fluenced by culture change.
1 How does an ongoing value of sex for reproduction affect our attitudes
toward relationships and sexual behavior that are not heterosexual?
2 How are sexual orientation and gender culturally constructed and expressed,
and how do sexual identities or orientations differ from sexual behaviors?
Suggested Resources
Books
Blackwood, Evelyn, and Saskia Wieringa, eds. 1999. Female Desires: Same-Sex Relations
and Transgender Practices across Cultures. New York: Columbia University Press.
Rust, Paula C., ed. 1999. Bisexuality in the United States: A Social Science Reader. New
York: Columbia University Press.
Eisner, Shiri. 2013. Bi: Notes for a Bisexual Revolution. Berkeley: Seal Press.
Websites
“LGBT Rights.” American Civil Liberties Union. https://www.aclu.org/issues/lgbt-
rights.
“Know Your Rights.” Lambda Legal. https://www.lambdalegal.org/know-your-rights?g-
clid=EAIaIQobChMIrd7N47ym5gIV24FaBR2iLQ7dEAAYASAAEgLpsvD_BwE.
15 Sex, Sexuality, and Gender
Chapter Overview
1 Examines gender roles relative to concepts of psychological masculinity
and femininity.
2 Incorporates an anthropological discussion of gender variance including
the transgender community in the United States and other industrialized
societies and cross-cultural gender variance.
Gender Identities and Gender Roles

Although concepts of gender identity (knowing that you are male, female, or
intersex) (Williams, 1986) and gender role (adopting culturally defined male
and female behavior) are probably widespread cross-culturally, their expression
is highly culture-specific. Chapters 1 and 2 discuss the symbolism of maleness
and femaleness and the diversity of gender role behavior among cultures (e.g.,
Margaret Mead’s classic work is one body of recently challenged research on
this topic: Mead, 1949, 1961 [1928], 1963 [1935]). We also know from the litera-
ture that culture change can impact gender roles cross-culturally (Lurie, 1973;
Radin, 1926; Sharp, 1981). However, the extensive amount of energy vested
in examining and trying to understand gender role behavior through the life
cycle in the late twentieth and early twenty-first centuries is largely a function
of middle-class industrialized and, specifically, US culture.
In this chapter, some of the current issues in male-female relationships, and
gender roles in mainstream US culture, as well as subcultures within the larger
society, are addressed. As part of the “Sexual Revolution” of the 1960s, a tre-
mendous amount of time, energy, and attention was directed toward defining
and elaborating concepts of gender role and gender identity, masculinity and
femininity.
The 1960s and 1970s alleged Sexual Revolution served as a sexual, social,
economic, and political statement against the perceived negative aspects of
traditional gender role behaviors and expectations. In its most extreme form,
anything defined as “traditional” was seen as negative. Some questions arose
as to whether a sexual revolution occurred (radical or root change, qualita-
tive, wide-scale, behavioral and attitudinal changes) (Ehrenreich, Hess, and
Sex, Sexuality, and Gender 365
Jacobs, 1986; Elshtain, 1989; Farrell, 1986; Goldberg, 1979, 1984), or whether a
reform movement occurred (a rebellion in which behaviors became more overt
and widespread, and attitudes remained relatively constant) (cf. Hendrick and
Hendrick, 1987; McCabe, 1987). Since the 1960s, sexual behaviors have be-
come more visible, open, and discussed in the culture. (Note the advent of
the Oprah and Dr. Phil television shows discussing sex issues and the portrayal
of sex on television in sitcoms and dramas.) The Sexual Revolution intro-
duced the concepts of liberated and androgynous gender role behaviors and
expectations. Androgyny advocates for situation-appropriate behaviors, not
gender-stereotyped behaviors. But whether there are qualitatively “new behav-
iors” and whether attitudes about sexual behavior have qualitatively changed
is arguable.
Gender identity may be the perception of oneself as a man or a woman or
another gender. In a biomedical, industrialized mode it rests on phenotypic
sex (i.e., the presence of male or female primary and secondary sex character-
istics) as well as an early, deeply ingrained sense of “I am a boy or girl, man
or woman.” Gender identity is labeled at birth. Gender role, which is learned
based on the gender identity, is the internalization of culturally recognized
attitudes, behaviors, beliefs, and values that complement one’s gender identity
and includes both verbal and nonverbal behavior, and relates to concepts of
masculinity and femininity.
Masculinity and femininity are patterned, learned, verbal and nonverbal
signs, symbols, and behaviors that reinforce socially defined concepts of gen-
der. Culturally specific, they include speech and dress patterns, activities and
affect, worldviews, and body language. The boundaries between innate and
learned aspects of gender role/identity and masculinity and femininity are
controversial and unresolved as the debates on various theories on left-and
right-brain dominance illustrate (Rogers, 2001).
Transgender People
Before we begin our discussion of both clinical and cultural definitions and
explorations of transgender people’s identities, expressions, and experiences,
we would like to share our positions on the following:
• Since this is the second edition of the book, many aspects about trans-
gender people’s lives have changed. Yet, we feel that including earlier lit-
erature on the subject provides an important historical context that is
relevant to understanding it more broadly.
• Specifically nomenclature and identity labels pertaining to transgender
people change and expand frequently, which means that by the time of
publication, the language used here may be outdated. However, we chose
to keep potentially offensive terms such as “transsexual” or “transvestite”
in the original text to stay true to the evolution of scholarship.
• The authors, especially those of us who have worked with transgender
individuals and organizations over many years, wish to emphasize that
we do not share the perspective of gender dysphoria being a mental
health pathology of any kind, although as of 2020, it remains listed in the
DSM-V-TR.
• Lastly, we emphasize that although this is a book on human sexuality, and
transgender people are commonly grouped under the LGBTQIA label, we
do not wish to conflate gender identity issues with sexual identity issues.
This has been a point of contention in the transgender community for
many years and we want to be clear that we separate these issues categor-
ically and ontologically.
Gender Dysphoria
Gender dysphoria1 is a clinical term that refers to distress felt by those who
are uncomfortable identifying with or behaving according to their culturally
assigned and defined gender (Harry Benjamin International Gender Dyspho-
ria Association, 2001; Money and Wiedeking, 1980). This clinical perspective
is codified in the various versions of the Diagnostic and Statistical Manual of
Mental Disorders (DSM). The DSM is published by the American Psychiat-
ric Association and is the handbook used in diagnosing mental disorders in
the United States (i.e., “DSM-V-TR”). It is currently in its 5th edition, pub-
lished in 2013. In 1980, the diagnosis of Transsexualism was introduced in
the DSM-III, and in 1994, the DSM-IV committee replaced the term with
gender identity disorder (GID) (The Harry Benjamin International Gender
Dysphoria Association, 2001). In the 2013 edition of the DSM-V, the terminol-
ogy changed again to replace GID with Gender Dysphoria (GD) (302.85). The
definitions and age-related specifications (i.e., GD in adulthood, adolescence,
and childhood) remain similar but reflect growing awareness of the diversity
and breadth of gender identities and expressions. According to the DSM-V-TR
(2013), Gender dysphoria refers to
the distress that may accompany the incongruence between one’s expe-
rienced or expressed gender and one’s assigned gender. Although not all
individuals will experience distress as a result of such incongruence, many
are distressed if the desired physical interventions by means of hormones/
surgery are not available. The current term is more descriptive than the
previous DSM-IV term gender identity disorder and focuses on dysphoria as
a clinical problem, and not identity per se
(451)
Similarly, Gender Identity Disorder Not Otherwise Specified (GIDNOS) was

also retained as a diagnostic category relabeled Unspecified Gender Dysphoria
(302.6).
As this review of DSM diagnostic terminology illustrates, social categories
are not stable over time and may change. This is true not only of the classifica-
tion categories used by the American Psychiatric Association, but social cate-
gories found in various sectors of society and in society at large as well. Social
labels are also useful to individuals because they provide actual or perceived
psychosocial connections, legal, and often economic protection, and political
or civic validation. “It is important to distinguish between self-constructed la-
bels and those that others impose on groups” (Kottak and Kozaitis, 1999: 164).
Thus, “what’s in a name?” is very important to individuals, especially to sexual
or gendered minorities, since it is related to concerns of power and voice. This
issue is relevant for transgender people since DSM-V classification is required
for those who desire to pursue hormonal or various surgical alterations. The
Harry Benjamin International Gender Dysphoria Association was the first in-
ternational organization who published the Standards of Care for Gender Iden-
tity Disorders (also referred to as HBIGDA Standards of Care) for professionals
with the goal of establishing parameters and clinical guidelines for treatment
of persons with GID thus linking professional standards of care with the DSM.
In 2006 HBIGDA changed their name to World Professional Association for
Transgender Health (WPATH).
The need for professional standardization of treatment guidelines for trans-
gender individuals arose nearly seven decades ago. In 1952 Christine (born
George) Jorgenson drew worldwide media attention by undergoing genital
reassignment surgery or sex reassignment surgery, then referred to as “sex
change surgery” in Denmark. Although not the first “sex change” surgery it
was certainly the most publicized. In the United States, the first genital re-
assignment surgery occurred in 1966 at the Johns Hopkins Gender Identity
Clinic (Bullough and Bullough, 1998: 15, 20). During the 1970s and 1980s
more than forty North American gender clinics were offering programs lead-
ing to surgical reassignment (Bolin, 1996a, 1998: 68). Coinciding with this was
a proliferation of grass-roots self-help organizations catering to the needs of the
nascent transgender community.
Prior to the early 1990s, transgender people were in their infancy as activ-
ist organizers, focusing on self-help and education (Bolin, 1996a: 470). They
stratified their own using social identities of “transsexual” and “transvestite”
(specifically heterosexual transvestite), separating themselves from sectors of
the lesbian and gay communities that also involved people wearing the ap-
parel of the other gender such as self-identified “drag queens” and “drag kings.”
During this era, pursuit of hormonal therapy and surgery was the sine qua non
of transsexual status. The social identity of transsexual evolved to refer to
people who believed themselves “trapped in the wrong body” and who psychi-
cally identified with the other gender. Those who claimed transvestite status
were people who may cross-dress intermittently and/or for extended periods of
time. It included but was not limited to those who felt compelled to cross-dress
and those who are aroused by cross-dressing. Over time the term transvestite
with its clinical and fetishistic implications came to be replaced by the term
cross-dresser, regarded as a much more acceptable and less negatively charged
social identity by community members and one that has gained widespread
usage since the 1980s (Bolin, 1996a, b, 1998). However, transvestic fetishism
remains as a DSM-V-TR (302.3) classification as a paraphilia, the psychiatric
term for problematic sexual desire or behavior (LeVay and Valente, 2002: 454).
It refers to a heterosexual male, who for at least six months, experiences “recur-
rent and intense sexual arousing from cross dressing as manifested by fantasies,
urges, or behavior” (DSM-V-TR, 302.3). There are many in the trans commu-
nity who find this classification objectionable (see below for discussion).
In the early 1990s, another term arose to describe gender variance. The
social identity of transgender originated in the community of people who
self-identify as transsexuals, cross-dressers, and those outside and between
these kinds of gender-variant options. Transgender as an umbrella term sup-
plants the dichotomy of transsexual and cross-dresser with a concept of con-
tinuity. It also reflects a growing acceptance of non-surgical options and the
recognition that there is a great deal of diversity in gender variant identities
not represented by the clinical and community categories of cross-dresser and
transsexual (Bolin, 2000: 27–30).
The transgender community is a reflection of the expanding political con-
cerns of involved individuals who want a voice in treatment, in defining them-
selves and in offering activities, support groups, and other events to further
their interests and needs as a growing community that gained momentum
throughout the 1980s. Thus, the social construction of identities has become
the cultural property of a community with a political and activist agenda for
transgender people’s rights. With trans-activism and its message of valuing and
respect for gender variance have come new possibilities for gendered identities.
There is currently a wealth of possibilities and ways to self-identify and many
transgender individuals now proudly and openly embrace their transgender
identities or histories.
Throughout the 1990s, transgender identities became even more expan-
sive and the boundaries between cross-dressers and transsexuals became
even more blurred representing the dual identity politics of consolidation
and disruption of gendered identities (Bolin, 1996a: 460–482, 2000: 27–30;
Broad, 2000: 255). Given this flourishing and revisioning of trans identities
along with the concomitant growth of trans-activism of the past thirty years,
it is not surprising that the DSM classification for GD and transvestic fetish-
ism has been challenged by individuals and organizations in the transgender
movement. For those in support of GD reform, the debate is centered on the
inclusion of GD and transvestic fetishism as psychosexual disorders in the
DSM-V-TR. Some activists argue that inclusion of these categories may be
used to support and validate intolerance of gender diversity in the commu-
nity, workplace, and courts, while others feel that pathologizing gender iden-
tities or expressions of any kind is discriminatory (Gender Identity Reform
Advocates, 2008; Wilson, 2000).
The question of etiology (exploring the causes or origins) of GID as a clin-
ical category is a complicated one enmeshed in the politics of identity. This
is particularly relevant since the search for causes is invariably framed as a
medical-clinical discourse with policy, insurance, and economic implications.
Although the cause of GID is currently unknown, various researchers have
offered theories to explain its occurrence. The literature on etiology spans the
diversity of identities in the transgender community, but emphasis is placed on
the self-identified and surgically oriented or post-surgical transsexual includ-
ing both male-to female and female-to-male transsexuals depending on the
particular study. We are sensitive to community preferences for the use of the
term transgender and we have added it where appropriate. However, since the
review of the research that follows emphasizes clinical literature, and trans-
gender was not a clinical term at the time, we have necessarily reproduced the
authors’ clinical terminology (usually transsexual) in order to more accurately
represent their research theories and findings.
Since bio-medical explanations for transsexual identity explore prenatal
and biochemical causes for its existence and expression, they are discussed
here along with psychodynamic explanations as well. There is a small cadre
of clinically oriented researchers who offer alternative explanations, including
those that link the transgender identity to sexual orientation. The problem
with these approaches is that they regard gender identity as derivative of sex-
ual desire, consider these as essential and eternal characteristics, and they ig-
nore the myriad ways identity and desire are derivative of cultural context and
hence variable. Transgender people, like their cisgender (i.e., non-transgender)
counterparts, are a diverse population with diverse desires. In fact, transgen-
der people may actually have more numerous possibilities for desire because
terms for sexual attraction are defined by gender of the actor and subject of
desire. For transgender people, sexual orientation as a critical characteristic for
gender identity is not a salient feature. Transgender people reiterate what the
cross-cultural record reveals: sexual orientation and identity are not coherent
and stable categories.
Anthropological and cross-cultural explanations and examples of gender
non-conformity and transgendered identities are usually referred to as gender
variance and are discussed in greater depth below. This research articulates
the relationships between broader gender systems, the social construction of
identity and sexuality.
Etiology of Transsexualism: Prenatal and Socialization

Explanations
Etiology or seeking the causes of transsexual identity is a prominent and a
prolific area of clinically orientated research activity. This question is ad-
dressed not just in the clinical areas as might be suspected but is also dis-
cussed by anthropologists and sociologists as well. Though paying respect to
the diversity of clinical approaches, it is perhaps not unfounded to suggest
that these perspectives tend to focus on the individual factors affecting the
development of a gender identity at variance with morphological sex. Such a
perspective tends to follow a disease model and may be construed as part of a
Euro-American process of the medicalization of gender variance. Researchers
emphasizing etiology are working from a medical model that stresses psycho-
analytic, social learning, or cognitive developmental theory and/or biogenic
variables.
In contrast, as will be discussed more fully below, anthropologists have
tended to look at larger domains stressing systems of interaction including
the gender and sexual system, gender relations, socialization, kinship, warfare,
and political and economic variables related to gender inequality (Besnier,
1996; Burton and Whiting, 1961 among many; Munroe, Whiting, and Hally,
1969; Nanda, 2000; Wikan, 1977, 2000). Rather than viewing the individual
as gender dysphoric as described in the clinical literature, the anthropological
model seeks to understand how gender variance links up with other cultural
institutions including the belief system around gender. Therefore, etiology is
considered by anthropologists in terms of social constructs as is gender.
The etiology of clinically defined transsexual identity is of interest because
it throws light on the broader subject of how gender identity is established
not only in transgender populations whose identity is in conflict with their
morphological sex, but also for the population at large for whom gender iden-
tity is not problematic. In addition, it provides insight into understanding the
cultural construction of gender in our society, and how gender is integrated
within systems of gender relations such as inequality between the sexes.
Clinical transsexualism is of interest to embryology because it has been
framed in the clinical literature as part of a nature/nurture or essentialist/
constructionist debate. Money (1986) was among the first and subsequent nu-
merous others to question this polarized argument as simplistic and unrealistic,
emphasizing the interaction of biology and culture, a position that even those
with a social constructionist approach do not find offensive. Today many the-
orists align themselves on the relative degree that they feel culture or biology
influences gender identity and expression. It is the clinical studies that we shall
draw on here in our discussion of fetal development, as these illustrate historic
and current debates in these fields.
Socialization Variables
Over nearly fifty years ago, Money and Ehrhardt (1972) and Stoller (1968)
regarded socialization variables as taking precedence over prenatal sex hor-
mones in the formation of cross-gender identity, although these researchers
acknowledged that there may be some unknown biological (hormonal meta-
bolic) factor in the prenatal environment that may play a role. Stoller’s model
points to maternal overprotection and paternal distance—either emotional or
geographical—in transsexual etiology. According to Stoller, the child fails to
identify with the father and becomes effeminate. Other researchers sharing
this view support the notion of a non-normative socialization, father absence
or prenatal dynamics such as a mother’s wish for a daughter (Cohen-Kettenis
and Gooren, 1999: 317). However, subsequent studies of these hypotheses were
not supported (Zucker and Bradley, 1995). Green (1974a, b) supports the view
that transsexuals share effeminate childhoods and then are subsequently chan-
neled into transsexualism as their options for normative gender identity devel-
opment have become closed off. Some support from the literature shows that
parental influences may be a contributing factor (Cohen-Kettenis and Arrindell,
1990; Garden and Rothery, 1992), but not necessarily a sufficient condition for
gender identity disorder (in Cohen-Kettenis and Gooren, 1999: 318).
Prenatal Biogenic Causes

The “parent” of the study of transsexualism, Dr. Harry Benjamin (1966), fa-
vored biogenic variables, even in those cases where socialization may have
clearly been a factor. Researchers have focused their energies on several bio-
genic variables including chromosomal, hormonal, and brain dimorphisms.
Hengstschlager et al.’s research with thirty male-to-female and thirty-one
female-to-male transsexuals found that “genetic aberrations detectable on the
chromosome level are not significantly associated with transsexualism” (2003:
639–640).
Eicher et al. (1981) and others have suggested that the H-Y antigen may be
atypical in transsexual people. In preliminary research Eicher found in his
research population of forty male-to-female and thirty-one female-to-male
transsexuals, that 84 percent were at variance with the norm. According to
Ohno (1979), “H-Y antigen is a cell surface component present in all male
tissues and absent in genetic females,” although this association is regarded
controversially as to whether it is a predictor of one’s sex. But Pfafflin (1981),
who studied transsexuals with a control group of non-transsexuals, found that
the non-transsexuals were atypical for H-Y antigen in about 50 percent of the
cases. This finding questions Ohno’s thesis that H-Y antigen is a predictor of
sex to begin with, therefore having little influence on gender dysphoric indi-
viduals. Since this research, H-Y antigen has been found to be produced by the
Y gene locus. The literature debates whether it is involved in spermatogenesis
(Jenkins, 1990) or in facilitating the development of the embryonic gonad into
testes (The American Heritage Dictionary editors).
Studies have also investigated hormonal atypicality. Others taking this
position include Starka, Sipova, and Hynie (1975) whose findings of lowered
levels of testosterone in seventeen male-to-female transsexuals, three transves-
tites, and four homosexuals have not been replicated and must be regarded as
“atypical.” The phenomenon of transsexualism is in fact noted for its normal
hormonal profile in individuals whose identity is variant.
Other research has linked gender differentiation of the human brain with
how transsexual persons process hormones. The implication is that hor-
monal atypicality may influence male and female differentiation of the brain
(Cohen-Kettenis and Gooren, 1999). It has been argued that the brain under-
goes differentiation into male or female as a result of prenatal hormones (Swaab,
2004: 302). Although both male and female fetuses are exposed to high levels
of estrogen prenatally, only males are exposed to high androgen levels that are
ten times higher in males than females at thirty-four to forty-one weeks of ges-
tation (Swaab, 2004: 302). However, there is disagreement about what actual
brain dimorphisms, if any, result. Although some research has suggested that
male and female brains are differentiated in the size and shape in the area of
the corpus collosum, Fausto-Sterling offers a compelling reexamination of the
problems with this research. Indeed only a few researchers have found sex dif-
ferences in the corpus collosum area, and studies of fetuses and children found
no difference; thus, if there is a difference it occurs with age (Fausto-Sterling,
2000: 131). Other researchers such as Manfredi-Romanini (1994: 783–787 in
Cohen-Kettenis and Gooren, 1999: 318) and Swaab (2004: 303) argue that
male and female brain differentiation may be due genetic factors, independent
of hormonal mechanisms.
Seyler et al. (1978) found female-to-male transsexuals’ hormonal responses
to DES (diethylstilbestrol) were intermediate, falling between the “normal”
female and male pattern. Migeon, Rivarola, and Forest (1969) administered
estrogens to male-to-female transsexuals and to control groups of non-
transsexual males and females and concluded that the transsexual hormonal
response to estrogen was atypical to both control groups. Though some pre-
natal hormonal disturbance suggests itself, Seyler and colleagues also offer the
possibility of a psychological factor since it is well documented that psycho-
logical states may be as causal as the effect of hormones. Lish et al. (1992) and
Money and Mathews (1982) have not found a correlation between children ex-
posed in utero to estrogens and transsexualism. Devor (1989) notes that cases
in which females have been exposed to androgens in utero have not increased
the incidence of transsexual people in those populations. Cross-sex identity
was not found in men or women exposed to progestins (which may have an-
ti-androgenic or androgenic qualities) in utero. Nor was it found in CAH girls
(prenatal exposure to relatively high levels of androgens) who were consis-
tently assigned and reared as girls or in cases of prenatal exposure to estrogenic
drugs, such as diethylstilbestrol (DES) (Collaler and Hines, 1995; Lish et al.,
1992 among others in Cohen-Kettenis and Gooren, 1999: 318–319). This line
of evidence presents a strong argument against the hormonal basis of gender
identity variance.
One other line of research emphasizing biogenic variables has been pur-
sued in regard to the etiology of gender dysphoria. This research has been
based on male and female differences in the size of the hypothalamus brain
cell nuclei, specifically that of the “central subdivision of bed nucleus of the
stria terminalis (BSTc)” (Cohen-Kettenis and Gooren, 1999: 319). Zhou and
colleagues (1995) examined the brains of homosexual men, heterosexual men
and women, and six male-to-female transsexuals. They found that male BSTc
were larger in males than females and that the male-to-female transsexuals
BSTc were within the size range for females, but was only 52 percent of the
volume of the BSTc in heterosexual men and 46 percent of homosexual men
(Breedlove, 1996; Zhou et al., 1995: 68). Sexual orientation was irrelevant in
the findings (Zhou et al., 1995: 68). The authors inferred a hormonal link, since
non-transsexuals who had taken estrogens for medical reasons did not have
smaller BSTc (Cohen-Kettenis and Gooren, 1999: 319) nor did menopausal
women or heterosexual men castrated to treat prostate cancer have atypical
BSTc for their gender (Breedlove, 1996; Zhou et al., 1995: 70). However, it is
not known when BSTc differences appear in individuals, and further evidence
may support possible long-term exposure to specific hormones as influencing
this variable. The transsexuals in the study had received long-term treatment
with estrogens. Currently we do not know what other factors are responsible
for this difference in BSTc in men or women, or in transsexual women re-
ported by Zhou and colleagues (Breedlove, 1996). This research has not been
replicated on transgender men.
Although there is strong support among some researchers for atypical social-
ization variables (Cohen-Kettenis and Arrindell, 1990; Garden and Rothery,
1992; Green, 1974a, b; Money and Ehrhardt, 1972; Stoller, 1968), other re-
search indicates the potential for a fetal hormonal atypicality (Benjamin,
1966; Eicher et al., 1981; Seyler et al., 1978; Swaab, 2004: 302) or other biogenic
factor (Zhou et al., 1995). Further research finds no support for either social-
ization or biogenic variables. Bower argues: “Despite intensive biological and
psychological research, the aetiology of gender identity disorders remains an
enigma. It may well be an interaction of genetic, hormonal and subtle psycho-
dynamic factors awaiting elucidation” (2001: 8).
A bio-cultural approach holds promise for understanding gender identity
and gender dysphoria. Bio-cultural perspectives are prevalent in the literature
on gender identity and point to the interaction of both biological and envi-
ronmental variables and the nature of this interaction. This is why they are
called interactionist or integrationist approaches (Archer and Lloyd, 2002).
In fact, Breedlove notes, “that for over thirty years neuroscientists have pro-
vided demonstrations that… experience can alter the structure of the brain”
(1996: 6). Devor’s research on female-to-male transgender people offers such an
approach to understanding gender dysphoria. She presents an inter-actionist/
integrationist approach to the development of gender identity in which the en-
vironment may be seen to potentiate prenatal influences either by inhibiting
their development or by enhancing it. According to Devor (1989: 22):
External environmental experiences set into motion a momentum, which

may be in continuation of pre-natal influences, or in contradiction to
them. In either case, social factors may be capable of overriding most, if
not all, prenatal influences. Social influences may actually reset the di-
rection which future development of a hormonal system will take. They
may act to suppress or enhance biological predispositions. If social forces
continue to exert pressure over long periods of time, a chronic situation
can develop which may crystallize into relatively stable physical configu-
rations that reflect the direction of social pressures. In this way, hormonal
abnormalities might be seen to be the result of chronic social abnormal-
ities… [O]ne might interpret the gross hormonal differences between so-
cially normal men and women as being a result, rather than a cause of the
chronic social pressures which males and females undergo in the process
of becoming socially normal men and women.
She concludes that the brain and its interacting endocrine system “learn” be-
haviors just as humans acquire behavior through cognitive processes. Thus:
“Not only is the human mind in dynamic interaction with its environment…
so too is the human body changing, learning and growing through its experi-
ence within its environment” (Devor, 1989: 22).
Gender Variance: Cross-Cultural Gender Diversity

The cultural specificity of gender identity categories such as maleness and fe-
maleness, masculinity and femininity, status and role variance are most dra-
matically represented by gender variance and diversity in the United States
and cross-culturally. The ethnographic record provides a rich history of soci-
eties whose gender schema offers social identities that exist beyond the United
States and the binaries of woman and man, girl and boy, female and male.
These positions include third or more genders, liminal genders (those between
male and female), intermediate genders, people who are “not men” and “not
women” and more (Nanda, 2000).
Anthropologists have referred to this spectrum of genders using a variety
of terms such as supernumery genders, third sexes and third genders, gender
transformed statuses and alternative genders, among others, and have generally
agreed at this point to use the term “gender variance” or “gender diversity” (Bolin,
1996b, 1998 [1996], 2000; Davies, 2007; Martin and Voorhies, 1975; Williams,
1986). In some nonindustrialized countries, the sex/gender system has created a
place for gender variant peoples through the social construction of multiple gen-
ders; in some these are legitimized and valued and in others not (Nanda, 2000).
The United States/European transgender social identity and the gender variance
found cross-culturally illustrates both the culture-bound (i.e., unique to a given
culture) dimensions and cross-cultural continuities of defining one’s gender within
the context of society. These topics are expanded in this section.
The Cultural Lens and United States Gender Variance:

Anthropological Perspectives
The anthropological literature on gender variance suggests the importance of
the cultural overlay in understanding gender diversity. Taking a traditional an-
thropological perspective, gender variance is situated in specific cultural con-
texts and historical moments. For example, a relativistic perspective toward
US gender variance challenged the notion that the transgender identity is a
“syndrome,” regarding it rather as rooted in the gender system whose rigidity
may have potentiated its development.
In contrast to the clinical perspective of the DSM-V-TR, an anthropological
perspective on US transgender identity emphasizes the cultural construction
of gender and its learned parameters. For example, in Bolin’s initial research
with transgender people in early 1980s (In Search of Eve: Transsexual Rites of
Passage, 1988a), the central question of “how can men become women in a
system where gender is regarded as an ascribed characteristic?” is part of un-
derstanding the Euro-American gender ideology about masculinity and fem-
ininity referred to as a gender schema (or belief system about how males and
females are distinguished).
A socio-cultural understanding of the US sex/gender system is necessary to
understand gender variance. Following the now classic theoretical model sug-
gested by Kessler and McKenna (1978), the Euro-American sex/gender schema
is a social construction that pretends to be biological (Tiefer, 2004). In this way,
culture impersonates nature and creates a set of beliefs about what is natural or
biological about gender. For purposes of clarification when referring to sex, we
mean those biological attributes related to reproduction, while gender refers to
those characteristics that are psychological and cultural: men and women, girls
and boys, masculinity and femininity. Central to the US/European cultural
gender schema is the notion that there are only two genders. This is regarded
as inevitable; it is an “incorrigible proposition” about what is constant and un-
changeable in reality (Kessler and McKenna, 1978). Gender is regarded as not
only binary or dichotomous but also as oppositional in industrialized societies.
The schema posits only two options: male and female with nothing in between
or outside of this dichotomy. As we shall explore shortly, this is a rather rigid
and polarized view of gender and one not necessarily universal and shared by
everyone.
Clearly the transgender identity is not a docile one. It creates rebellious
bodies—hybrid and intersex ones that create disarray and challenge not only
medicalization, but threaten central tenants in the Euro-American gender
schema as biological attributes, gender identity, role concomitants, and gender
of erotic interest are rearranged and recombined in new ways by those in the
gender variant community.
Since the gender revolution of the 1960s, elements of the Euro-American
gender schema have been assaulted from diverse sectors and various fronts
to challenge the biological implications of gender roles (e.g., notions about
femininity and masculinity, such as women are “naturally” more emotional
and men more aggressive), but in the United States we have not gone so far as
to challenge the system of gender as dichotomous and to remake it into a sex/
gender system that defines gender as continuous (cf. the classic work of Kessler
and McKenna, 1978).
In summary, we have suggested, US transgender identity is a social creation
subject to change and the subjectivity of individuals, who may reproduce but
also resist and challenge dominant ideologies. In the next section we will focus
on cross-cultural gender variance. At this juncture it is important to note that
Euro-American ideologies of gender have variously collided and fused with
indigenous gender statuses including gender diverse ones. Through coloniza-
tion, nationalization, and globalization, indigenous gender variance has under-
gone extreme transformation in industrialized and nonindustrialized nations.
Nanda (2000: 6) summarizes this cogently:
Culture contact is an important source of change in sex/gender ideolo-

gies and identities. Throughout the contemporary world and, and since
the first European encounters with non-European cultures, ideologies of
sex/gender diversity have been influenced, changed, and, as in the pre-
contact Philippines and American Indian societies, practically destroyed.
This diffusion of Euro-American culture continues today through tourism
(including international sex tourism), the global media, and the spread
of academic and scientific discourse. [Worldwide] Euro-American sex/
gender identities such as “gay” and “lesbian,” have been incorporated into
traditional sex/gender ideologies, though often in ways that change their
original meanings. The widespread incorporation of Western ideas means
that in most societies today several sex/gender systems—indigenous and
foreign—operate simultaneously, with gender variant individuals moving
between and among them as they try to construct their lives in meaning-
ful and positive ways.
Cross-Cultural Gender Variance

As we have seen, the US transgender identity is embedded in the wider
Euro-American gender schema, sometimes reproducing, but also challenging
beliefs and assumptions about embodiment as a male or female through the
creation of hybrid bodies and identities. The Euro-American gender schema
assumes that there is coalescence between physical characteristics such as
genitals, gender status, gender identity and social identity. However, not only
does the transgender community challenge these views, but the ethnographic
spectrum presents a much more complicated picture than the view that anat-
omy necessarily leads to a gendered destiny. Nanda (2000: 2) argues: “Many
cultures do not make the distinction between the natural and the cultural or
between sex and gender, for many cultures, anatomical sex is not the dom-
inant factor in constructing gender roles and gender identity.” For example,
occupation or the kind of work one does may be a more important attribute of
gender than are genitalia, once the initial assignment at birth is made on the
basis of visual inspection. For some Native American groups it was possible for
a physiological female to become a social male by taking on the occupation of
men (Besnier, 1996; Bolin, 1996b; Nanda, 2000; Whitehead, 1981).
Further complicating the picture of gender identity is sexual expression/
behavior with people of the same sex/gender. Homosexual behavior does not
carry the same meaning cross-culturally. Until recently in the United States
the LGBTQ communities were bifurcated around sexual orientation and gen-
der identity, with transgender people forming a community based on issues of
identity, not sexual interest. Weiss (2007) has argued that these divisions are
being eroded, specifically that the borderlands between butch lesbian iden-
tity and FTM (female-to-male transgender identity) are being broken down by
the younger generation. These social identities are beginning to converge as
a result of changes in both communities, as youth cultures blur and erase the
borders between lesbian and FTM identities. In this regard, Weiss (2007: 219)
suggests:
In 1998, Dr. Jacob Hale wrote about a “borderland” between butch les-
bian identity and FTM masculinity, suggesting a “demilitarized zone.”
While the intervening years have brought no “demilitarized zone,” the
border may not have a long future. Converging trends in identity among
the younger generation in their teens and twenties suggest this, such as
changing meanings of “lesbian” and “FTM,” blending of sexuality and
gender, and understanding these as personal, rather than identity, differ-
ences. The socio-historical circumstances that gave power to anti-trans
feminist attitudes and trans rejection of lesbian identity are disappearing.
This is not to say that we are “post-lesbian” or “post-transsexual” but the
tension between identities, the need to distinguish clearly between them,
and the arguments about who is “really” lesbian or “really” FTM may be of
supreme unimportance to the next generation. Time will tell.
However, other societies have gender schemas that incorporate gendered ho-
mosexuality. In this situation the insertee or recipient of anal intercourse takes
on characteristics and behaviors associated with the feminine gender role and
feminine social identity. Unlike the United States gender schema, in Brazil,
one’s position as a recipient of homosexual anal intercourse defines one as
gender variant; the inserter is not considered homosexual or gender variant
(Kulick, 1998; Nanda, 2000). In some nonindustrialized countries, the sex/
gender system has created a place for various gender variant peoples through
the social construction of multiple genders, outside, inside and in between.
Although gender variance is legitimized and valued in some nonindustrial-
ized/industrializing societies, in others it is not. There is a tremendous amount
of diversity in the way gender variant peoples and cultures define, experience
and practice gender variant identities, statuses and roles; for some peoples such
as Plains Native Americans and some Hindus, it may be part of a sacred or reli-
gious experience and for others it is secular (Nanda, 1999, 2000). For example,
Thayer’s (1980) analysis argues that gender variance among Northern Plains
Indians represents an interstitial positioning of gender between the secular
and the sacred (in Bolin, 1987a, b) and in contrast Besnier (1996) notes that
Polynesian gender variance has no historical or current association with the
religious.
From its early days through today, anthropologists have been document-
ing and analyzing this panoply of genders; for example Bogoras reported on
the Chuckchee “softman” in 1907. The cross-cultural study of gender vari-
ance reveals the limitations of our own Euro-American perspective of gender.
Scholars and researchers are not immune to the power of the industrial gender
schema to frame their analysis of the expression and meaning of gender vari-
ance, even when trying not to. Consequently it is far preferable in a discussion
of cross-cultural gender variance to use the indigenous or local name for the
gender variant identity, for example alyha for the Mohave male gender variant
status and mahu for the Polynesian “liminal” gender. It may be acceptable to
use the generic “two spirit” as a generic reference to Native American male
and female gender diversity (Lang, 1998). One major caveat relates to our
modern terminology that differentiates gender status/identity from gender role
and gender of erotic/sexual interest. The anthropological literature offers dis-
tinctions between these four insignias of gender in interpreting, for example,
whether a woman who behaves like a man is a cross-gendered or gender trans-
formed status, or whether such behavior is just part of gender role variability
for women (Bolin, 1996b, 2004b; Lang, 1998).
This is a subtle distinction that may be more evident through example than
explanation. Among the Northern Piegan, a highly sex-disparate culture stud-
ied by Lewis (1941), women could assume attributes associated with masculin-
ity through participation in economic venues. Among the Piegan, to acquire
wealth and display generosity had even higher prestige than war. Women who
pursued this career were known as manly hearts. The manly hearts were asser-
tive women characterized by aggression, independence, boldness, and sexual-
ity, all traits associated with Piegan masculinity (Lewis, 1941: 181f). But to be a
manly heart also required that one be wealthy and married. In this regard they
were highly valued as spouses because of their economic contributions. The
manly hearts gender was not a transformed status, although they “acted like
men.” Manly hearted women cursed like men, excelled in men’s and women’s
work, and generally behaved in ways associated with the masculine role but,
were essentially gendered as feminine in that they did not use their skills to
escape the gender constraints of being a wife and mother. The Piegan manly
hearts role inscribed the privileging of masculinity for both males and females,
while women’s pursuits were valued in women only (Lang, 1998: 305–306).
We must keep in mind that the distinction between gender statuses and gen-
der role may not be an emic one. A related point in the consideration of gen-
der diversity is that when gender varies, then Euro-American paradigms that
gender and sexual orientations are oppositional are dismantled rather rapidly.
When gender is destabilized then so is sexual orientation. Gender variance
also disrupts Euro-American notions of sexual orientation. US polarization of
homosexual and heterosexual does not translate well into the ethnographic
record as we saw in the case of Latin America wherein only the receptor in
anal sex is regarded as homosexual (Kulick, 1998). This polarization has also
been under cultural assault in the United States in the new millennium by
youth (queering and questioning), and the recognition of a category of “men
who have sex with men” (MSM) (Hess et al., 2017).
A final point in the cross-cultural study of gender variance is that the
ethnographic record is decidedly thin on female supernumerary/transformed
statuses and female same-sex relations as well. In spite of the considerable con-
tributions of a cadre of women anthropologists including the valiant efforts of
Evelyn Blackwood who has dedicated her research to this subject area since
1984—including Blackwood and Wieringa (1999b), Blackwood (1999), Elliston
(1999), Lang (1998), and Whitehead (1981) among others—the study of female
gender variance and same-gender sexual behaviors is still in its infancy and
much work remains to be done. The classic anthropological literature on ad-
ditional/transformed genders is biased heavily toward examples of presumed
genetic/genital males and male gender variance is reported among many more
societies than for females (Lang, 1998). Unfortunately, since we offer discus-
sion of the classic ethnographic literature, our examples will necessarily reflect
this emphasis in the literature. However, women also occupied these positions.
Whether female two-spirit genders and other expressions are similar to male
gender variance is unclear (Lang, 1998). It may be argued convincingly that,
because gender statuses are structured differently for women and men globally,
gender variant statuses for women may not be expected to be mirror images
of men’s gender variance. In fact, Nanda (2000: 7) asserts: “[F]emale gender
diversity has its own cultural dynamic and is not simply a derivative, a parallel,
or the reverse of male gender diversity” (Nanda, 2000: 7). The bias in the liter-
ature has been speculated upon and may be explained as follows:
• There is a general cultural valuing and privileging of males among many

but not all cultural groups.
• There may have been observer bias of male researchers (who dominated
the field in its early days).
• Male researchers lacked access to females.
• Female gender variance is simply less obvious to the observer.
• It may be related as well to more rigid boundaries around the male sta-
tus so that transgression leads to additional genders. The female role is
more accommodating of diversity so that women may have more freedom
to cross over roles without transforming their gender as in contemporary
North America (Bolin, 2004b; Lang, 1998: 261–267; Nanda, 2000).
A final caution: although many cultures have gender variant positions for men
and women to transgress their gender by acting like or being identified with
the other gender, these must be understood within the context of the specific
culture at a specific point in time, since social identities are dynamic, situa-
tional, and contextual (Nanda, 2000: 4). Towle and Morgan (2006) offer a
cautionary voice to the use of the term “third gender” warning that in spite of
the acceptance of diversity implied by this term, it paradoxically signifies an
industrialized classification and appropriation of indigenous gender variance,
obscures the heterogeneity and complexity of gendered social identities. As a
consequence, we have relegated the term “third gender” to those examples in
which the author uses the term.
Although cross-dressing may be part of gender variance, very transient

cross-dressing for ceremonial purposes is not defined as gender variance.
Transient cross-dressing is found in many cultures and on many occa-
sions. It is frequently associated with ritual events such as among the
Iatmul men of New Guinea who mockingly dress as elderly matrons
(Bateson, 1958); among the Dani when women don the garb of young
warriors to celebrate; and in the United States in the “powder puff foot-
ball” of an earlier era, with men and women reversing the gendered di-
vision of players and cheerleaders. Rituals that include gender reversals
occur in numerous other groups as well as in Brazilian Carnaval.
The spectrum of gender variance cross-culturally is a wide one and includes

a number of examples in which some of the gendered behaviors usually as-
sociated with one gender/sex are adopted by those of another in part or in
whole; these are broadly conceived to include demeanor, dress, activities, and
occupations; and may or may not converge with sexual expression. One of the
ways that cultures recognized and institutionalized gender variance is through
codification in the indigenous lexicon that recognized the status of individuals
who were in some ways divergent from the cultural gender paradigm in terms
of anatomy, gender status and/or behavior.
Classic ethnographic reports on gender variant identities suggest it was once
widespread among indigenous peoples prior to colonization. Westermarck
(1956) offered the first ethnological overview in 1906. Stewart (1960: 19) re-
corded its presence among Native Americans for Kroeber’s Culture Element
Distributions (1937–1943), Devereux (1937) among the Mohave, Hoebel (1949)
and Lewis (1941) reported it for Plains Indians; Hill noted it among the Navajo
(1935) and Pima (1938), Bogoras for Chuckchee (1904–1909), Evans-Pritchard
for the Azande (1970), among others. And more recent accounts covering
pre-colonial and colonial gender variance among Native Americans (includ-
ing men and women) include, for example, Lang (1998), Williams (1986), and
Roscoe (1991, 1998) for the Zuni. Anthropological literature on gender vari-
ance in light of the influence of globalization is also growing; examples of
this work include Davies (2007), Towle and Morgan (2006), Matzner (2001),
Sinnott (2004), and Blackwood (1999, 2005a), among others.
Although the current trends in anthropological approaches to understand-
ing gender variance are very context specific emphasizing local culture and
gender ideologies, other approaches have used the cross-cultural correlational
method to test hypotheses generated by the ethnographic accounts. This ear-
lier research has focused on identifying the relationship between gender vari-
ance and gender roles. For example, Hoebel (1949) proposed that the male
gender variance (two spirits) represented male protest in societies in which
the extant warfare complex demanded excessive male aggression. However,
Goldberg’s test of this hypothesis found no correlation between warfare and
two-spirit traditions. Downie and Hally (1961) and Munroe, Whiting and
Hally (1969) correlated male gender variant identities with societies that had
low sex role disparity (differences) rather than high as previously suggested in
Hoebel’s research. They hypothesized that societies that had low gender role
disparity would be more likely to have gender variance because it would make
it easier for the “predisposed” to change genders, arguing that these societies
would be more tolerant of gender variance.
Williams’ (1986) historical and ethnographic research argued that the
Native American two-spirit traditions were an additional gender mixed sta-
tus rather than just role variation for men (Callender and Kochems, 1983).
Williams’ analysis proposed that the two spirit must be understood in light
of Native American spiritual systems wherein one’s spirit is the most import-
ant aspect of sex/gender in contrast to the industrialized gender schema with
its genital focus. Williams cited the enhanced status of the two spirit among
Native American groups whose gender relations included a high valuation of
women. He suggests that “[b]ecause women are valued, androgyny is allowed,
but if women are devalued, are regarded as polluting, female characteristics in
males will be denied” (Williams, 1986: 268–269).
Levy’s (1973) research on the Tahitian mahu (gender variant status for men)
has also argued that gender variance is related to the gender paradigm and
gender role disparity, as has the earlier research discussed above by Downie
and Hally (1961), Munroe, Whiting, and Hally (1969), and Williams (1986).
Levy’s interpretation of Tahitian gender variance, unlike previous research-
ers, maintained that the mahu, as a third gender, was vital in making gender
difference apparent. Tahitian society is one in which gendered behavior is not
clearly polarized; therefore, the mahu identity served as a way to culturally elab-
orate the differences between men and women. Besnier (1996) has taken issue
with Levy’s interpretation of the mahu, proposing that the mahu is not a third
gender, but rather a gender liminal position embedded in Polynesian views of
personhood. Moreover, Besnier (1996: 307) contends: “the mahu blurs gender
categories rather than affirms them… [in a society where]… gender boundar-
ies are anything but blurred.” Matzner’s (2001) research on O’ahu transgender
people (male bodied) incorporates narratives to reveal the complexities of the
current overlay and fusion of the colonial experience, immigration and global-
ized transgender identity with the mahu of Old Hawaii.
Wikan’s (1977, 2000) study of Omani xanith (a male gender variant posi-
tion) relates this third gender to socioeconomics, gender relations, roles, and
sexuality. A man could become a xanith temporarily to earn income through
sex work with heterosexual men. According to Wikan, the xanith gender was
an important social position that functioned to preserve female honor by pro-
viding an inexpensive sexual outlet for heterosexual male desire. This was a
flexible and an intermittent gender; a xanith could resume his position as a
man, including marriage and family, without negative repercussions.
Anthropological research has and continues to demonstrate that gender
variance can take many forms in addition to what we have discussed. One
line of research has reported on intersex individuals among a number of cul-
tures. Intersexuality provides society the opportunity for cultural creativity
in response to genital variation from the anatomical norm. As discussed in
Chapter 7, an intersex person may be identified at birth (but not invariably) by
the appearance of the genitals. Societies have responded in diverse ways to the
presence of people with intersex genitals; for example, the traditional (preco-
lonial) Navajo culture provides an example of a society in which an intersex
status was a highly valued one (Bolin, 1996b, 2004b; Hill, 1935, Lang, 1998).
The Navajo recognized three physical sexes: intersex, males, and females,
and at least three or more gender statuses: men (boys), women (girls), and na-
dle. There were three categories of nadles: real nadle and nadle pretenders who
may be genital men (males) and women (females). The nadle were ascribed
their position on the basis of ambiguous genitals; or in the case of the nadle pre-
tenders, they displayed interests ascribed to the other gender. Therefore, either
genital or psychic/behavioral ambiguity qualified one for the status. The nadle
assumed occupational tasks and behaviors associated with both men (with
the exception of hunting and warfare) and women. But they also had special
status not shared by other Navajo; they were in fact regarded as extraordinary
people associated with prosperity. In the words of one Navajo: “They know
everything. They can do the work of a man and a woman. I think when all the
nadle are gone, that it will be the end of the Navajo” (Navajo consultant to
Hill, 1935: 275). Nadle sex partners included women or men, but not other na-
dle or nadle pretenders. Women could therefore select as sexual partners men,
nadle, or nadle pretenders, and men could choose as partners women, nadle,
or nadle pretenders. However, homosexuality, defined as intercourse between
partners of the same gender, was not accepted among the Navajo. This serves
to illustrate problems of interpretation cross-culturally. If the nadle was a third
gender status or something other, then the term homosexual is inapplicable
to nadle partnerships. Such relationships cannot be classified within our in-
dustrialized schema based on heterosexuality, homosexuality, or bisexuality
(Bolin, 2004b).
Another example of gender variance associated with, but not limited to,
genital ambiguity bears mentioning and that is Serena Nanda’s study of the
hijras of India (1999, 2000). The hijras are a recognized third gender, who
are usually born as men (although some may be born intersex) and become
transformed through a ritualized surgical emasculation in which the genitals
(penis and testicles) are removed. Hijra translates as “eunuch” or “intersex”
and emphasizes sexual impotence; defined as having no desire for women;
making them “not men” (Nanda, 2000: 29). After the surgery, they adopt the
demeanor, behavior, and clothing of women, but they are still “not women”
because Hindu womanhood implies marriage and children. Although hijras
are like women in taking feminine names, using female kinship terms for
each other, and wearing women’s dress, they also violate norms of feminine
behavior by public dancing, use of aggressive speech, verbal insults and exag-
gerated expressions of dress and demeanor.
Central to understanding the hijra are the religious elements of the position.
These “neither man nor woman” worship Bahuchara Mata, a Hindu Mother
Goddess associated with transgender people. The surgical emasculation comes
at the bequest of their goddess. Only through the surgery, a form of rebirth
religiously, can the hijras enact the procreative power of the Mother Goddess.
These procreative powers are enabled through the hijras’ performance at life
cycle events including marriages and in rituals after the birth of a child. They
perform songs, dances, and blessings for fertility in the name of their goddess
and receive traditional payments of money, sweets, and cloth.
Hijra gender variance suggests a flexible gender category. The ideal for hijras
is that of the life of an ascetic in which sexual desire is renounced. Through
the renunciation of sexuality and reproduction, sexual desire is transformed
into sacred power. But as a variant third gender, the hijra community attracts
different kinds of persons, most of whom join voluntarily as teenagers or adults.
It appears to be a magnet for those with a wide range of cross-gender charac-
teristics arising from diverse motives. The hijra gender accommodates different
personalities, gender identities, and sexual needs, including persons who have
sex with men (sometimes for money) or the ideal of an ascetic sexless life with-
out losing its cultural meaning. It is embedded in Hinduism which celebrates
the coexistence of unresolved oppositions in the acknowledgment of multiple
genders existing among both gods and humans. Thus, the person who does not
marry and cannot have children is not excluded from a place in Hindu society
but can become a hijra (Nanda, 1999, 2000; Nanda and Warms, 2007).
Not only is gender variance associated with ideologies of gender, fertility,
and the spiritual system, but it may also occur in a nexus of gender and mar-
riage such as in the woman marriage still practiced today among some peoples
(Brockman, 2004). It has been recorded for thirty Bantu societies, including a
dozen Kenyan ethnic groups (O’Brien, 1977). Woman marriage is a predomi-
nantly African institution where one woman marries another and becomes a
female-husband. There are a number of types of woman marriage, but debates
occur over the kinds of sexual practices associated with this form of marriage
and/or whether a woman-husband is a third gender, a transformed gender or
an expression of gender role variance. For example, the Igbo of Nigeria do
not limit male gender roles to just male bodied people but allow females to fill
male gender roles without sacrificing their position as women. This suggests
that gender status is not necessarily linked to particular bodies (Amadiume,
1987). Among some groups, women may marry women for economic inde-
pendence, but will not necessarily be regarded as social men (O’Brien, 1977).
Oboler’s (1980) work among the Nandi notes that female-husbands do take
on men’s roles and tasks such as cultivating and herding. However, Blackwood
(1986) maintains that woman marriage was not a cross-gender institution, al-
though reports suggest a great deal of diversity in this marital form. Blackwood
(1986) also maintains that same-sex behavior may have been part of this type
of marriage, while the majority of researchers consider woman-marriage a non-
sexual institution. Evans-Pritchard’s (1951) early research on woman marriage
among the Nuer maintained that it occurred in situations where a female was
infertile. The infertile woman would take a wife, hence becoming a cultural
man. She would also arrange for a progenitor for the wife so that she could be-
come a father. Evans-Pritchard’s (1951) interpretation of woman-woman mar-
riage was that it functioned as a kin recruitment strategy thereby optimizing
the potential loss of kin through an infertile woman (Evans-Pritchard, 1951;
more recently Blackwood, 2004).
The meaning of what it is to be a woman-husband in this institution is not
resolved, nor is it clear whether lesbian relations occurred within these rela-
tionships (Blackwood, 1999, 2004). Indeed, if the woman-husband is regarded
as a man, then the term lesbian is ethnocentric. Blackwood proposes that
woman-marriage presents a “model of relations between women within the
gender system” rather than a gender crossing role (1986).
In summary, what can we learn from this panorama of gender variance and
how can it inform the Euro-American gender schema? We propose that:
• Gender variance reveals our Euro-American dichotomous gender classifi-

cation system as just one of many paradigms.
• We can learn from these tribal voices that man and woman, male and fe-
male are not universal categories for gender, that there may be more than
two as testified by the intersex genders, hijra, and the two-spirit traditions.
• Gender variance is very complex, incorporating a great deal of diversity
within gendered categories, contesting notions of bipolarity, and suggest-
ing liminality and diversity beyond that offered by the notion of third
genders (e.g., status and role variation).
• Gender identities may be achieved and shed within one’s lifetime.
• Categories such as homosexuality and heterosexuality are exploded when
gender is destabilized.
• The ethnographic record has indeed revealed a fluidity and flexibility in
sexual behaviors and choice of sexual partners that suggest an indepen-
dence of identity and sexuality.
• Intersex genders indicate that identities are not clearly or directly tied to a
detectable biological baseline/hormonal environment but are interpreted
through the cultural paradigm.
• Cross-gendered roles suggest the embeddedness of concepts such as mas-
culinity and femininity in culture (Bolin, 2004b).
This cross-cultural overview of gender variance demonstrates the differences

between the anthropological and the clinical approaches to this subject. Both
anthropologists and clinicians are concerned with understanding gender
variance, but it is encountered from two very different perspectives. Though
the clinical is distinguished by its search for biological and psychological fac-
tors, the socio-cultural perspective is interested in the cultural construction
of gender and how gender variance is anchored in broader systems of gender
ideologies and relations within the cultural context, emphasizes the impor-
tance of cultural meanings, including gender subjectivity in the experience
and socio-cultural expressions of gender variance within the totality of a gen-
der system (e.g., Blackwood, 2005a; Herdt, 1999). Transgenderism and cross-
cultural, alternative gender roles such as the xanith, mahu, and manly-hearted
women are examples of the cultural variety and response to gender identity.
Our fascination with gender identity extends to various beliefs concerning
gender statuses and roles, changing gender role behaviors, and how to manage
gender relations in the twenty-first century.
Cross-Cultural Gender Roles: Traditions and Changes

Traditional gender roles refer to those preferred behaviors and expectations
that are clearly gender specific and are associated with male and female
middle-class behavior from the late 1800s to the mid-1960s. These include
affective and behavioral characteristics based on gender which tend to empha-
size female passive-aggressiveness, overt displays of emotion other than anger,
as well as those emphasizing nurturance, intuition, gentleness, and softness.
Male behavior is sharply contrasted: aggression, emotional constriction other
than expressions of anger, rational-logical interpretation, decisiveness, and
hardness.
Androgyny is a Greek word combining the words for male, andros and fe-
male, gyny. It refers to a state of being in which an individual behaves, thinks,
and emotes in response to the situation, regardless of gender-defined charac-
teristics. As a situation-specific response, it synthesizes culturally defined cat-
egories of male and female behavior such as femininity and masculinity. For
example, fear is a common human reaction to a threatening or dangerous situa-
tion. Traditional males in the United States would show no fear; females would
express fear. An androgynous individual would express fear as the appropriate
response to the situation regardless of gender. Androgyny extends from behav-
ioral-affective situations to include modes of dress, speech, and demeanor in
popular US culture (e.g., gender-neutral clothes or colors). Culturally, androg-
ynous behavior and affect are still androcentric or male oriented and easier to
achieve for females than for males. For example, while both men and women
now wear earrings, this was a difficult and not totally resolved barrier for men
to cross. Men’s earrings tend to be less ornate, smaller, and simpler than wom-
en’s, and currently may be worn in either or both ears. In contrast, women can
freely shop in men’s clothing departments and be considered stylish. There is
little fear or chance of reprisal or discrimination toward women who do this.
The concept of androgyny may be very culture specific, even within indus-
trialized societies. Some cross-cultural examples may help to illustrate this.
Within other societies which have roots in European traditions such as Latin
America, there is a very clear recognition and acceptance of men’s culture and
women’s culture.
Among Latinx, men and women know who they are and accept, sometimes
with anger and resentment, that men and women are different. They behave
very differently in each other’s presence, particularly in public, than they do
when they are with their own gender. These changes can be subtle— a shift
in facial expression or body posture, or more overt—such as changes in the
volume, inflection, or tone of voice, vocabulary used, or the topics considered
appropriate for discussion in a mixed group. Through affinal ties, one of your
authors, Patricia Whelehan, belongs to an extended Peruvian kinship system,
which encompasses three continents and islands in the Caribbean. These
households are middle class and female centered. However, the presence of a
male, particularly an older one, shifts attention away from the females to his
needs. Females, for example, create their own space in several ways when men
appear. There are clear distinctions in space between en casa (home) and al
fuera (outside, the public/work world). Home is women’s space. Women attend
to the man’s desire for food and drink in order to “take care of him and get him
out of the way.” Women can move to another area of the house or engage in
a “female activity” such as cooking, being with other female family members,
or going shopping with them. Although this behavior takes them out of the
house, it also serves to assert their space (Whelehan, n.d.).
An even clearer example is found in Muslim societies in the Middle East.
Purdah is the veiling and seclusion of women. It is perceived by many in indus-
trialized societies as an extreme situation of female submission to and oppres-
sion by men. However, in the classic book, Guests of the Sheik, Fernea (1965)
discusses the gradual changes in her perception of purdah, and her eventual ac-
ceptance of it for herself and the women with whom she lived. Veiling, which
is done in public and in the presence of unrelated males, provides women
with a sense of privacy, space, and protection. Women are not veiled in their
own space at home, which is considered one of the most important sectors of
Muslim society. At home, they make decisions that are integral to daily life
and the welfare of the family. Veiling separates them from a male world which
they do not necessarily want to join, nor which they necessarily define as su-
perior to their own. They know that their work and effort maintains the kin
group, a key survival unit in society.
The effect of culture change on gender roles, sexuality, and relationships
can be exemplified by looking at the Mosuo, a group located in western China
near the Tibetan border; the twenty-first-century Sambia; and the residents of
Pohnpei (formerly spelled Ponape), a group of islands in Micronesia. Tradition-
ally, the Mosuo, a matrilineal and matricentered society, practiced a form of
polyandry, called “walking marriages,” where women had a number of sexual
partners. Sexuality was viewed positively among the Mosuo, particularly for
women, who could openly discuss their own sexuality and were expected to
have many sexual partners. In the anthropological biography Leaving Mother
Lake: A Girlhood at the End of the World, by Yang Erche Namu and Christine
Mathieu, Namu, the protagonist who now lives in San Francisco, discusses the
changes in her village and among the Mosuo after Mao Zedong (Tse-Dong/tung
alternate spelling) came into power. Chairman Mao introduced radical social
and economic changes in China, including those related to sexuality. Tradi-
tional villages were disbanded, people were sent to forced work camps, and a
strict sexual morality of monogamy, an abolition of premarital sex, and a one
child per family policy were instituted. The sexual freedom previous genera-
tions experienced all but disappeared from public view (Namu and Mathieu,
2003). More recently the Chinese government has regarded and promoted the
Mosuo as a tourist attraction.
Among the Sambia, extensively studied by the anthropologist Gilbert
Herdt, and discussed in Chapter 11 there have been radical changes in both
male socialization and the expression of male and female gender roles (2006).
Currently, Sambian young adults are leaving their villages, moving into their
own apartments away from extended kin, and adult spouses and lovers are liv-
ing together. Heterosexual couples are sharing household responsibilities and
women are demonstrating more authority in their relationships. Some younger
adult Sambian males even deny that the male insemination ceremonies ever
occurred (Herdt, 2006; Knauft, 2003).
Martha Ward’s work among the residents of Pohnpei provides a third ex-
ample of changing gender roles and expectations (2005). “Night crawling,”
carried out by adolescents who were attracted to each other, has been replaced
by dating. The traditional diet, which was largely provided for by women, is
being replaced by convenience and highly processed foods from the United
States and Europe, resulting in health problems such as diabetes, high blood
pressure, and obesity. Traditional pregnancy, birth, and postpartum practices,
which focused on the extended female kin group and which allowed women
to rest and regain their energy after pregnancy and birth, are being replaced
by “modern” biomedical obstetric practices that include increasing use of
drugs and monitoring during pregnancy, a reduction in home births, and an
extended postpartum period. Ward was pregnant during her field work and
gave birth in a US hospital. She notes the differences in pre- and post-natal
practices, especially those in the United States, which did not include a
strong, female-centered basis of psycho-emotional support. The full impact
these gender role and sexual changes will have for individuals and groups in
both in the United States and cross-culturally is yet to be realized. Without
romanticizing traditional ways of life, these changes can have serious conse-
quences for the kinds of social, psychological, and economic support individ-
uals and groups experience.
Summary
1 Gender role is an expression of gender identity.
2 Gender role is culturally defined and expressed.
The cross-cultural expression of gender variance is explored.
3 US transgender identity is presented from a historical and cultural
perspective.
4 The concepts of androgyny and gender were developed in the 1970s to
explain gender role expression in US culture.
1 To what extent are fundamentalist social and religious movements within
the United States and cross-culturally a backlash to the changes in sex-
uality, gender roles, and relationships that have been occurring since the
late twentieth century in industrialized societies, particularly the United
States?
2 Based on what you have read about the US transgender identity and
cross-cultural gender variance, how do you weigh in on the issue of biol-
ogy and gender in gender variance?
Suggested Resources
Books
Blackwood, Evelyn and Saskia Wieringa, eds. 1999. Female Desires: Same-Sex Relations
and Transgender Practices across Cultures. New York: Columbia University Press.
Cromwell, Jason. 1999. Transmen and FTMs: Identities, Bodies, Genders and Sexualities.
Urbana: University of Illinois Press.
Green, Jamison. 2004. Becoming a Visible Man. Nashville, TN: Vanderbuilt University.
Herdt, Gilbert, ed. 1996. Third Sex/Third Gender: Beyond Sexual Dimorphism in Culture
and History. New York: Zone Publishing.
Website
World Professional Association for Transgender Health. www.wpath.org.
16 Sexual Health
HIV, AIDS, and Sexually
Transmitted Diseases
Chapter Overview
1 Defines HIV infection and AIDS, placing it in the context of other
sexually transmitted infections (STIs) and sexually transmitted diseases
(STDs).
2 Discusses the epidemiology of HIV/AIDS globally.
3 Presents the biomedical aspects of HIV and AIDS.
4 Discusses HIV testing.
5 Discusses the sexual transmission of HIV and the controversies surround-
ing safer sex.
6 Explores the impact of HIV/AIDS on women in the United States and
elsewhere.
7 Discusses the political, economic, and socio-psychological factors in HIV
transmission, risk, prevention, and treatment in the United States and
cross-culturally.
8 Places the HIV/AIDS epidemic in a global context.
9 Presents the controversies surrounding drug and needle transmission of
HIV.
Introduction
Sexuality is one of the more complex dimensions of our humanity. One
place where this complexity is more obvious is when we explore the topic
of sexually transmitted infections (STIs) and sexually transmitted diseases
(STDs), specifically Human Immunodeficiency Virus (HIV) and Acquired
Immune Deficiency Syndrome (AIDS). This chapter highlights HIV/AIDS
as one of the most significant challenges currently confronting human
societies.
STIs/STDs can be acquired through the transmission of bodily fluids from
an infected individual to another person. STIs can be viral, bacterial, fungal,
or parasitic. STDs are the physical effects that happen to one’s body once
infected with an STI. These can include fevers, sores, fertility problems (par-
ticularly for females), and for those untreated STIs such as HIV and syphilis,
390 Sexual Health
death at their end stages. Common STIs include syphilis, chlamydia, and hu-
man papilloma virus (HPV). Syphilis and chlamydia are both treatable and
curable, as are genital warts. Even though chlamydia is not fatal, if left un-
treated it can cause infertility in women. HPV and herpes simplex 2 (HS2)
are both viruses, as is HIV. But HPV and HS2, while incurable, are not fatal,
and are easily treatable. A vaccine has been created to prevent HPV. Treat-
ments for these other STIs generally involve a short course of antibiotics or
other therapies, not a daily, lifelong regimen of treatment, as there is for HIV/
AIDS. This is important because STIs such as syphilis and gonorrhea can act
as risk factors and increase the likelihood of contracting an HIV infection.
This means that having one of these other STIs increases one’s risk for HIV
either by impairing one’s immune system or causing sores that make HIV more
readily transmissible.
Diseases such as the bubonic plague during the Middle Ages, syphilis,
and leprosy have played an important role in the physical, social, economic,
political, and psychological responses of societies over the past several hun-
dred years. In today’s society, HIV is the disease confronting us with global
and culture-specific significance and it affects industrialized, industrializ-
ing, and nonindustrialized countries. This disease, first identified by the
media in the United States in 1981 as GRID (Gay-Related Immune-defi-
ciency Disease), a misnomer, is now identified as HIV, which is a worldwide
phenomenon1.
There is neither a cure nor a vaccine for HIV/AIDS, and it is fatal if left
untreated. HIV infection can be treated with anti-retroviral medications
(ARVs), sometimes referred to as HAART (Highly Active Anti-retroviral
Therapy) with dramatic improvement in people’s health and their lives. How-
ever, these drugs are expensive, are not widely available outside of developed
societies, and can have serious side effects. People who take the drugs must
adhere to a strict daily schedule of dosage in order for the treatment to be
effective. Also, Pre-Exposure-Prophylactics (PrEP) that can be taken before
exposure to HIV and Post-Exposure Prophylactics (PEP) that can be taken
after exposure to HIV are available. These medications can stop HIV from
taking hold in the body.
Aside from the biological differences between HIV and other STIs, there
are socio-cultural, political, and economic factors that impact the course
of HIV/AIDS. As will be discussed, HIV/AIDS is global (pandemic) and is
found on all inhabited continents with devastating consequences for the
individuals, groups, and societies. Poverty, local and international political
decisions, and practices that are based more on “morality” and ideology
than science affect risks for infection and the course of the disease once
infected. The stigma that accompanies the HIV/AIDS pandemic shapes so-
cietal response to it to a greater degree than other STIs. For these reasons,
this chapter focuses on the HIV/AIDS pandemic. Table 16.1 compares HIV
to other STIs.
Table 16.1 Common sexually transmitted infections (STIs) and sexually transmitted diseases (STDs): mode of transmission, symptoms, and treatment
Diseases characterized by vaginal discharge
STD Transmissions Symptoms Treatment
Bacterial vaginosis Caused by a build up of Women will experience a fishy or musty smelling, pasty Metronidazole (Flagyl),
Gardnerella vaginalis discharge, which is usually gray, along with pain itching or Clindamycin cream,
bacterium, usually transmitted burning in or out of the vagina, and burning when urinating. Clindamycin oral pills, or
from sexual interaction Most men are asymptomatic. Tinidazole
Vulvovaginal The Candida albicans fungus Women could experience a white, “cheesy” discharge, vulvar Vaginal suppositories
Candidiasis may accelerate growth when edema, fissures, excoriations. Men are unaffected. or cream, such as
(yeast infection) the chemical balance of the clotrimazole, nystatin,
vagina is disturbed; it may also miconazole, terconazole,
be transmitted through sexual and butoconazole. Men
interaction. receive similar topical
treatments.
Trichomoniasis The protozoan parasite Most infected persons are asymptomatic (70%–85%) Metronidazole and
Trichomoniasis vaginalis Women may experience white or yellow vaginal discharge Tinidazole are used to
is transmitted through with an unpleasant odor, and an irritated vulva. Men treat both sexes.
genital sexual contact. Less may experience symptoms of urethritis, epididymitis, or
frequently, it has been found prostatitis.
to be transmitted by towels,
toilet seats, or bathtubs used
by an infected person.
Chlamydial The Chlamydia trachomatis Asymptomatic infection is common among men and women. Azithromycin,
Infection bacterium is transmitted In men, chlamydial infection of the urethra may cause a Erythromycin,
primarily through sexual discharge and burning during urination. Chlamydia-caused Lexvofloxacin, or Ofloxacin.
contact. It may also be spread epididymitis may produce a sense of heaviness in the affected
by fingers from one body site testicle(s), inflammation of the scrotal skin, and painful
to another. swelling at the bottom of the testicle. In women, chlamydial
infection may cause PID, ectopic pregnancy, disrupted
menstrual periods, abdominal pain, infertility, elevated
Sexual Health 391
temperature, nausea, vomiting, and headache.

(Continued)
Gonococcal The Neisseria gonorrhoeae Most common symptoms in men are a cloudy discharge Ceftriaxone or
Infection bacterium (“gonococcus”) from the penis and burning sensations during urination. Azithromycin are
(Gonorrhea or is spread through genital, If the infection is untreated, complications may include usually effective
“clap”) oral-genital, or genital-anal inflammation of scrotal skin and swelling at the base of in uncomplicated
contact. the testicles. In women, some green or yellowish discharge infections of the cervix,
392 Sexual Health
is produced but commonly remains undetected. At a later urethra, and rectum.

stage, PID may develop. Other treatments
include Cefixime and
Spectinomycin.
Nongonococcal Primary causes are believed to be Inflammation of the urethral tube. A man has a discharge Azithromycin,
urethritis bacteria Chlamydia trachomatis from the penis during urination. A woman may have a Doxycycline,
(NGU) and Ureaplasma urealyticum, mild discharge of pus from the vagina but often shows no Erythromycin, Ofloxacin
most commonly transmitted symptoms.
through coitus. Some NGU
may result from allergic
reactions or from Trichomonas
infection.
Syphilis The Treponema pallidum Primary stage: A painless chancre appears at the site where Benzathine penicillin,
bacterium (“spirochete”) is the spirochetes entered the body. Secondary stage: The tetracycline, or
transmitted from open lesions chancre disappears and a generalized skin rash develops erythromycin.
during genital, oral-genital, or and swollen lymph nodes and fever. Latent stage: There
genital-anal contact. may be no observable symptoms. Tertiary stage: Heart
failure, blindness, mental disturbance, and many other
symptoms may occur. Death may result.
Pubic lice Phthirus pubis, the pubic louse, Persistent itching. Lice are visible and may often be located Preparations such as
(“crabs”) is spread easily through body in pubic hair or other body hair. A-200 pyrinate or
contact or through shared Kwell (gamma benzene
clothing or bedding. hexachloride).
Herpes The genital herpes virus (HSV- Small, red, painful bumps (papules) appear in the region of No known cure; a variety
2) appears to be transmitted the genitals (genital herpes) or mouth (oral herpes). The of treatments may
primarily by vaginal, oral- papules become painful blisters that eventually rupture to reduce symptoms; oral
genital, or anal sexual form wet, open scores. acyclovir (Zovirax), oral
intercourse. The oral herpes Valacyclovir, and oral
virus (HSV-1) is transmitted Famciclovir may reduce
primarily by kissing. symptoms.
Viral Hepatitis A Hepatitis A is caused by the Symptoms include fever, fatigue, loss of appetite, nausea, Vaccine preventable; No
Hepatitis A virus (HAV). It vomiting, abdominal pain, dark urine, diarrhea, clay- specific therapy other
can be transmitted from fecal- colored stools, joint pain, and jaundice. than bed rest and fluid
oral route or consumption of intake.
contaminated food or water.
Also transmissible through
colitis with infected person.
Viral Hepatitis B The Hepatitis В virus may be Vary from non-existent to mild, flu-like symptoms to No specific therapy;
transmitted by blood, semen, an incapacitating illness characterized by high fever, treatment generally
vaginal secretions, and vomiting, and severe abdominal pain. consists of bed rest and
saliva. Manual, oral, or penile adequate fluid intake.
stimulation of the anus are
strongly associated with the
spread of this virus.
Genital warts The virus is spread primarily Warts are hard and yellow-gray on dry skin areas; soft Topical agents like
(venereal warts) through genital, anal, or pinkish red, and cauliflower-like on moist areas. podophyllin:
oral-genital interaction. Most cauterization; freezing;
are caused by some strain of surgical removal; or
the human papilloma virus vaporization by carbon
(HPV). dioxide laser. Vaccines
have been developed to
prevent infection with
some strains of HPV.
Sexual Health 393
(Continued)
Acquired Immuno- Blood and semen are the major Varies with the type of opportunistic infections (OIs) that At present, therapy focuses
Deficiency vehicles for transmitting affects someone with HIV. Common systems include: on specific treatments of
Syndrome the AIDS virus, HIV, which fevers, night sweats, weight loss, loss of appetite, fatigue, opportunistic infections
(AIDS) attacks the immune system. It swollen lymph nodes, diarrhea and/or bloody stools, and tumors. Since 1996,
appears to be passed primarily atypical bruising or bleeding, skin rashes, headache, combination therapy
394 Sexual Health
through sexual contact chronic cough, a whitish coating on the tongue or throat. has increased survival
or needle sharing among rates and decreased
injection drug abusers. Can progression to AIDS and
be passed perinatally from susceptibility to OIs in
mother to fetus or during those people who have
breastfeeding. access to the drugs and
can tolerate their side
effects.
Pelvic This often occurs when you This is an infection of a woman’s reproductive organs. Cefotetan, Doxycycline,
Inflammatory have an STD and do not get Symptoms include pain in the lower abdomen, fever, Cefoxitin, Gentamicin
Diseases (PID) treated; have more than one unusual discharge, pain or bleeding during intercourse,
sex partner; have had PID burning sensation during urination, or bleeding between
before; and are sexually active menstrual cycles.
and are twenty-five or younger.
Lymphogranuloma Caused by three strains (L1, L2, Most commonly found in men. In the first stage, small Doxycycline, Erythromycin
Venereum and L3) of the C. trachomatis lesions at the site of entry will occur. In the second stage,
(LGV) bacteria. inguinal lymph nodes become tender and the skin around
the pubic becomes inflamed. Discharge pus and blood may
also be found. In the third stage, lesions will heal with
scarring, but persistent inflammation may be observable.
Chancroid The Haemophilus ducreyi Symptoms are commonly found in both men and women. Azithromycin, Ceftriazone,
bacteria is transferred during Symptoms include anogenital ulcers and swollen lymph Ciprofloxacin,
sexual intercourse. nodes. Erythromycin
Information included above can be found at https://www.cdc.gov/std/default.htm

Sexual Health 395
Sexually Transmitted Diseases
Anthropology and medical anthropology have definite roles to play in resolv-
ing the AIDS pandemic. At the beginning of the twenty-first century, HIV/AIDS
is a global problem. As such, HIV/AIDS is described as a disease and topic of
study that fits well with an anthropological perspective. The physical, biological,
socio-cultural, political, and economic aspects of HIV/AIDS filter through each
society’s values, beliefs, and institutions in relation to health, illness, disease, sex-
uality, gender, life, and death. Since anthropologists have a history of qualitative
as well as quantitative research, we have the ability to discern the symbols and
constructs underlying people’s behaviors, and we work in intercultural health set-
tings (AIDS and Anthropology Research Group, 1988; Carrier and Bolton, 1991;
Herdt et al., 1990; Herrell, 1991; “National Institutes of Health Consensus De-
velopment Conference on Interventions to Prevent HIV Risk Behaviors,” 1997).
HIV/AIDS affects people globally across the life cycle. The anthropological per-
spectives of cultural relativism, cross-cultural comparison, and a holistic approach
to data are helpful in understanding the cultural complexities of this disease.
Please note that the material in this chapter is current through 2019. While
some information about HIV infection and AIDS such as modes of transmis-
sion, risk reduction strategies, and safer sex has remained relatively constant over
the past several years, other aspects such as treatment modalities, incidence rates,
and prevalence patterns are changing rapidly. Contact your local department of
public health, AIDS task force, campus AIDS coordinator, or the CDC (Centers
for Disease Control and Prevention) for the most up-to-date information.2
Epidemiology of HIV/AIDS
A basic knowledge of epidemiology, which is the study of the patterns of dis-
ease, helps us understand HIV/AIDS anthropologically. Knowing how many
people and who are infected with or at risk for HIV can help to develop in-
tervention programs from prevention and testing to treatment and care. In
addition to being a pandemic, HIV/AIDS is also endemic, meaning that it is
well-established in the populations where it is found. For example, about 27.2
percent of Swazilanders in South Africa have AIDS (“World Health Organi-
zation: AIDS Country Statistics, 2019). HIV/AIDS seems to have appeared
rather suddenly among men who have sex with men (MSM) in Los Angeles,
New York, and San Francisco during the summer of 1981 (Shilts, 1987). The
sudden appearance of a disease that spreads relatively quickly through a popu-
lation is referred to as an epidemic. The number of new cases of HIV/AIDS is
referred to as the incidence rate. In 2017, 38,739 people received an HIV diag-
nosis in the United States, and the rate of infected peoples has been declining
9 percent since 2010 (CDC Fact Sheet, 2019. HIV/AIDS is an epidemic, a
pandemic, and endemic in societies where it occurs.
HIV/AIDS also takes on acute, chronic, and terminal aspects of disease
and illness. Acute diseases have a sudden onset and a relatively rapid course
of infection. Colds and the flu are examples of acute diseases. The acute aspect
396 Sexual Health
of the disease occurs in the beginning months of being infected. About two
thirds of people with HIV experience flulike symptoms within the first two to
three weeks of being infected (HIV.Gov “Symptoms of HIV”). Chronic diseases
that are incurable can affect people’s functioning but may be treatable. Arthri-
tis and diabetes are examples of chronic diseases. HIV/AIDS is incurable, but
those people who have access to and can afford anti-retroviral therapy (ARVs/
HAART) live longer and function reasonably well. Terminal diseases are those
that kill you. Some cancers and some forms of heart disease are terminal. HIV/
AIDS is terminal for those who do not have access to HAART/ARVs. This in-
cludes most of the people outside industrialized countries who have the disease.
Disease refers to the clinical and physical manifestations of being sick: fevers,
night sweats, and weight loss are all the other physical aspects of HIV/AIDS.
Illness refers to the socioeconomic, psychological, and political aspects and con-
sequences of having a disease. For people with HIV/AIDS, these aspects can
include stigma and isolation from kin groups and friends, inability to work, with
resulting economic problems, as well as the effects that grief and the loss of pro-
ductive members of society have on the rest of the group. HIV/AIDS exemplifies
the core of epidemiological work (see Tables 16.1 and 16.2).
Table 16.2 Regional/global HIV/AIDS statistics
Region Adults (age New HIV Adult (age Adult (age

15+) and infections 15–49) 15+) and child
children living among adults prevalence deaths due to
with HIV/ (age 15+) and (%), end AIDS in 2006
AIDS, end children, end 2006
2017 2017
Western and central 6.1 million 370,000 5.9 280

Africa
Eastern and 19.6 million 800,000 0.6 380,000
southern Africa
Latin America 1.8 million 100,000 0.5 37,000
North America 8 million 43,000 0.8 18,000
Asia and the Pacific 5.2 million 280,000 0.9 170,000
Western/Central 2.2 million 70,000 0.3 13,000
Europe
Caribbean 310,000 15,000 1.2 10,000
Middle East/North 220,000 18,000 0.2 98,000
Africa
Global 36.9 million 1.8 million 1.0 2.9 million
Source: “Regional HIV and AIDS statistics and features in 2017 by UNAIDS research fund.”
https://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf.
Demographics of HIV/AIDS
Age
Demographic variables of age, gender, socioeconomic status, ethnicity, and lo-
cation are also important in understanding the risks for and the manifestations
Sexual Health 397
of HIV/AIDS in a population. HIV/AIDS is classified as either pediatric when
it is found in people younger than twelve years old, or adult when it is found
in people older than fifteen. Currently, most pediatric HIV/AIDS cases are
a result of mother-to-child-transmission. A mother can transmit HIV to her
child during pregnancy, childbirth, or breastfeeding if her HIV-positive status
is unknown and/or she does not or cannot receive drugs to prevent transmis-
sion (see Tables 16.2 and 16.3).
Table 16.3 United States HIV/AIDS statistics 2017
US HIV/AIDS statistics
People living with HIV/AIDS, US 1.1 million

People newly infected with HIV, US 38,700
African Americans as a proportion of new AIDS diagnoses in the US 43% (13%)
(and their percentage of the US population)
Hispanics/ Latinos as a proportion of new AIDS diagnoses in the 26% (18%)
US (and their percentage of the US population)
Caucasians as a proportion of new AIDS diagnoses in the 26% (64%)
US (and their percentage of the US population)
1 Opt-Out| Pregnant Women, Infants, and Children | Gender | HIV by Group | HIV/AIDS |
CDC https://www.cdc.gov/hiv/group/gender/pregnantwomen/opt-out.html (2019).
Table 16.4 AIDS cases by age
Age Estimated # of AIDS Cumulative estimated # of

cases in 2017 AIDS cases, through 2005a
Ages 13–14 25 1,015

Ages 15–19 1,723 5,309
Ages 20–24 6,416 34,987
Ages 25–29 7,755 114,519
Ages 30–34 5,678 194,529
Ages 35–39 4,365 209,210
Ages 40–44 3,032 165,497
Ages 45–49 3,006 103,326
Ages 50–54 2,729 57,336
Ages 55–59 1,918 30,631
Ages 60–64 1,008 16,611
Ages 65 or older 885 14,606
a Includes persons with a diagnosis of AIDS from the beginning of the epidemic through 2017.
Source: From CDC, http://www.cdc.gov.
Although HIV/AIDS is generally seen as a younger person’s disease with

most people worldwide infected in mid-to-late adolescence and early adulthood
(fifteen to twenty-four years old), at least 24 percent of AIDS in the United
States is diagnosed among people older than fifty (Edwards, 2005). It is increas-
ingly found in older people in Thailand as well as the United States (“HIV
and AIDS—United States 1981–2001,” 2001; Im-em, 2002; Im-em et al., 2002).
398 Sexual Health
Reasons for this include increased longevity for people who have access to
ARVs, changing sexual morals, a value on sexuality across the life cycle as part
of Thai and US culture, and denial about risk for HIV among divorced, wid-
owed, or separated middle-aged people who find themselves single and dating
(Im-em et al., 2002).
Gender
Gender is a major risk factor for HIV/AIDS. HIV is primarily transmitted
through unprotected penile and anal intercourse. (See specifically the section
on Women and HIV/AIDs later in this chapter.) While initially HIV/AIDS
was seen as a disease of “middle-class gay identified men” in Euro-American
industrialized societies (and thus the early misnomer of GRID), and the elite
in both Brazil and some sub-Saharan African societies in the 1980s, it has
become a gendered epidemic in the twenty-first century. In 2017 adult and
adolescent women made up 19 percent of the new HIV diagnoses for that year
(CDC: HIV among women). Sub-Saharan Africa accounts for 70 percent of
the global burden for the HIV/AIDS infection, which women and adolescent
girls bearing a disproportionate infection rate (Kharsany and Karim, 2016).
Women in this region are eight times more likely than their male counterparts
to become infected with HIV (Kharsany and Karim, 2016).
Socioeconomic Status
HIV/AIDS rapidly moved in the 1980s from an epidemic of the middle class
in various parts of the world to a disease of the poor and disenfranchised by
the 1990s and early twenty-first century. In the United States, it is increasingly
a disease found among poor, urban, ethnic minorities. Cross-culturally, from
sub-Saharan Africa to India and Southeast Asia, most of the people infected
and affected by HIV/AIDS are poor. Most of the people in sub-Saharan Africa
earn less than US $2 per day, with women, on average, earning less than that.
The cheapest ARVs available cost US $1 per day, making them unaffordable to
most of the people who need them (Farmer, 2000; Farmer, Walton, and Furin,
2000). This aspect of HIV/AIDS has led activist anthropologist/physician Paul
Farmer and others to call AIDS a disease of poverty.
Table 16.5 Simple comparison of men and women

living with HIV/AIDS in 2016
United States Percent (%)
Male 77a
Female 23
a US totals include two males in the Pacific Islands and

one person from New York whose sex is unknown.
Source: “CDC Fact Sheet 2017.”
Sexual Health 399
Ethnicity
Ethnicity is another salient variable when discussing HIV/AIDS. Most of
the people with HIV worldwide are People of Color. Proportionately, most
of the people in the United States with HIV/AIDS are African American
and Latino, with Native Americans and Asian-Pacific Islanders also dispropor-
tionately affected given their prevalence in the population. In 2017, African
American people accounted for 43 percent of new HIV diagnoses but only
made up 14 percent of the total United States Populations (CDC: HIV and
African Americans). Hispanics/Latinos made up 26 percent of the new HIV
diagnosis in 2017 (CDC: HIV and Hispanics/Latinos). About 83 percent of
the women with HIV/AIDS in the United States are African American or
Latinx. It is no coincidence that most of these people are also poor, and that
their overall health, nutrition, and living conditions become co-factors for in-
fection (Cummings et al., 1999; “Fact Sheet: The HIV/AIDS Epidemic in the
US—2005 Update,” 2005; Farmer et al., 1996) (see Table 16.3).
Cultural Disparities
Since people’s behavior occurs and is expressed through their cultures’ norms,
values, and structures, the disparate socioeconomic and political situations
that exist within and between societies all influence the risk for HIV. These
disparities have been created and maintained through colonialism, global
markets and culture change. Socially, we have seen throughout this book
that sexual behavior is influenced by patterns of descent and residence and
the degree to which patricentricity (degree of centering around male father
figures) or importance of extended kin groups plays in people’s lives. Eu-
ro-American colonial practices changed sexual norms by generally lowering
women’s status in society and making them dependent on males, as well as
creating economic and political practices that benefitted colonial powers to
the detriment of indigenous groups (Flint and Hewitt, 2015; Jolivette, 2018;
Maju et al., 2019). In the grand mix of culture contact and change with vast
discrepancies in access to goods and services, sexual behavior has become the
major conduit for HIV worldwide. Specific examples from subcultures in the
United States and from certain Global South countries can highlight what
has happened.
The demographic profile of people living with HIV/AIDS (PLWH/A) in
the United States has changed drastically over the past four decades of the
epidemic. Currently, HIV/AIDS increasingly occurs among poor, ethnic and
female populations. African Americans, Latinx and Native Americans com-
prise a disproportionate percentage of HIV/AIDS cases in the United States.
Socially, preventative programs that work for men who have sex with men are
not appropriate for other groups, as they do not reflect these groups’ norms and
values. Economically and politically, African Americans, Latinx, and Native
Americans experience discrimination relative to employment, health services
400 Sexual Health
and self-determination. There also exist fewer preventative and treatment re-
sources for these communities than for the white middle-class (Centers for
Disease Control and Prevention, 2017b; Verissimo et al., 2018).
In 2017 (Centers for Disease Control and Prevention, 2017b):
• 41.1 percent of all reported HIV cases in the United States were among
African Americans.
• Sixteen percent of all reported HIV cases in the United States were
among the Latina.
• 9.9 percent of all reported HIV cases in the United States were among the
American Indian/Alaska Natives community.
• 5.1 percent of all reported HIV cases in the United States were among the
white and Asian community combined.
The most likely reason that ethnic minorities are at a higher risk of HIV is
due to a long history of systemic racism, which often leads to limited access
to quality health care, lower income and educational levels, and higher rates
of unemployment (Centers for Disease Control and Prevention, 2017b). These
realities leave little capacity for sexual health to be a priority or topic of knowl-
edge. If there is lack of knowledge about STIs among a community, it is not
rare for individuals to be unaware that they have them, and thus can lead
to further transmission. Another possible reason for higher rates of HIV and
STIs among these communities may be due to stigma, fear, discrimination,
and homophobia, both from their own community and others. The cultural
beliefs within a community may result in less safe sex practices. For example,
in many Latinx families there is a machismo value, which expects women to
be monogamous and for family and tradition to be greatly respected. This may
mean that a woman who insists on using condoms raises questions about her
behavior and the integrity of her male partner (Brooks et al., 2005; Centers
for Disease Control and Prevention, 2017a). Preventing the conception of chil-
dren may be seen as disrespectful. In certain communities, individuals who are
HIV positive are discriminated against and thus they are afraid to get tested
or discuss it, for fear of rejection. Getting tested may also mean an individual
has to disclose their sexual orientation when they are not ready or do not feel
comfortable (Reif, Wilson, and McAllaster, 2018).
Many of these communities are othered by the majority white population
and had long-standing culture and traditions infiltrated by early European
contact and long-standing white supremacy. Not only are Native American
populations among some of the poorest in the community, but they also re-
ceive some of the worst health care (Baugher et al., 2019; Urban Indian Health
Institute, 2019). Some Native American traditions include two spirits, or third-
or-fourth gender people; however, European powers stigmatized and penalized
these practices, therefore making them far less common or accepted among
the Native Americans themselves. This can lead to risky sexual behavior due
to denial and shame (Lee, Thompson-Robinson, and Dodge-Francis, 2018).
Sexual Health 401
Location
Location plays a role in HIV/AIDS. As stated, 70 percent of the AIDS cases
occurs in Sub-Saharan Africa, but this region only accounts for 12 percent of
the global population (Kharsany and Karim, 2016). The reasons for this are
largely socio-economic and political and are discussed in other sections.
Epicenters of HIV/AIDS in the United States refer to those cities that are
AIDS “dense” (i.e., have high incidence and prevalence rates of HIV/AIDS).
Washington DC is the city with the highest number of cases of HIV/ AIDS
on record. The majority of people who receive an HIV diagnosis live in urban
areas (CDC, 2019c). Cities tend to have higher incidence and prevalence rates
than rural areas in the United States for reasons of population density, greater
access to HIV testing and treatment that provide the basis for reporting and sta-
tistics, more population diversity, and a greater overall tolerance for a variety of
lifestyles and behaviors than occur in more rural areas. United States epicenters
tend to cluster on the coasts and in major industrial areas (see Table 16.4).
In both the United States and in nonindustrialized societies the incidence
and prevalence rates for HIV/AIDS are probably under-reported. There are
several reason for this. One, reporting is based on HIV test results and AIDS
diagnoses. As a highly stigmatized disease and illness, not everyone who is at
risk for infection or who is infected gets tested and diagnosed. It is estimated
that about 15 percent of the people with HIV in the United States do not
know they are infected (HIV.gov., 2019). Two, testing and diagnosis depend
on having an infrastructure and resources available within a group to carry
out the tests and diagnosis. That is expensive and unavailable to most people
at risk and with HIV/AIDS worldwide. Last, since HIV/AIDS is stigmatized,
there are political reasons for individuals, groups, and societies to neither know
their HIV status nor to keep records. Active discrimination against people
with HIV, moral condemnation from some fundamentalist religious groups,
and loss of employment and health insurance can contribute to inaccurate
epidemiological data.
Modes of Transmission and Co-Factors

Modes of transmission and co-factors for HIV risk are part of the epidemiol-
ogy of HIV/AIDS. Modes of transmission refer to how HIV is spread. There
are four basic modes of transmission: (1) through blood and any of its products,
(2) through semen, pre-seminal, rectal, and vaginal fluids, (3) through breast
milk, and (4) from mother-to-child transmission (MTCT) during pregnancy
or childbirth. The behaviors that can transmit these fluids include unpro-
tected anal, vaginal, and to a significantly lesser extent, oral sex with males
or females; sharing HIV-infected blood through needle usage; and during
the peri- and postnatal period, including breastfeeding (Bartlett, 2006). The
Centers for Disease Control and Prevention (CDC) and the World Health
Organization (WHO) keep track of the modes of transmission of HIV.
402 Sexual Health
Risk co-factors for HIV are those variables that do not transmit the virus,
but which may increase one’s risk for infection. They include other STIs which
impair one’s immune system or which may create sores or blisters that make
it easier for HIV to pass through the skin. Other factors that can impair a
person’s immune system include using drugs that can also affect one’s decision
making, malnutrition, and overall poor heath that may leave a person with
sores that ease the passage of the virus, and poverty. Poverty creates the foun-
dation for these other co-factors to flourish. Poor people do not have the same
kinds of “choices” that middle-class and wealthy people do relative to food,
clean water, preventive medical care and treatments, and safer sex. Heath care
workers are also at risk population because they are interacting with infected
persons and can come into close contact with bodily fluids. The modes of
transmission and co-factors have a synergistic effect in increasing one’s risk for
infection with HIV.
Biomedical Aspects of HIV/AIDS

HIV/AIDS is one of the more recent diseases in human history, and its inci-
dence and prevalence indicate that it may be one of the most serious diseases
encountered. While not the most common or most easily transmitted STI
or virus (colds, measles, and the flu are all caused by viruses that are much
more readily transmitted than HIV), HIV has had a horrific impact on those
groups where it is found. HIV is a retrovirus for which currently there is no
cure. A retrovirus is one in which its genes are in the form of RNA; generally
viruses have their genes in the form of DNA which transfer to RNA. With
HIV and other retroviruses, this process acts in reverse. This means that HIV
is transferred into the DNA of a cell. Since HIV inserts itself into the DNA,
it continues to replicate itself. This is one of the reasons that developing a
preventive vaccine is so challenging. There are two major forms of HIV that
affect humans, HIV-1 and HIV-2. HIV-1 is the most virulent form found world-
wide; HIV-2 is less virulent and largely found in parts of West Africa (Alcamo,
2003; Stine, 1997). However, there have been developments of different treat-
ment options that make it easier to live with
HIV is a bloodborne, not airborne virus and mutates rapidly in the human
body. This is one of the reasons why finding a preventive vaccine is so difficult
and why it is so important for people with HIV to take their ARVs consis-
tently in order to avoid having the virus develop resistance to the drugs. HIV
slowly destroys the body’s immune system, and in doing so makes the person
with HIV susceptible to a number of opportunistic infections (OIs). OIs are
diseases caused by bacteria, fungi, or protozoa such as TB, Pneumocystis carinii
pneumonia (PCP), or thrush that usually do not occur in people with healthy
immune systems.
Within two to three weeks of being infected with HIV, about 50 percent of
people develop flulike symptoms. Since these symptoms are vague and similar
enough to the flu, most people do not associate them with being HIV infected.
Sexual Health 403
After about one month of being infected, about 50 percent of people develop
a sufficient number of antibodies to the virus that they can be detected with
an HIV test. After three months, more than 95 percent of the people who are
infected will have detectable antibodies, and after six months, more than 98
percent of infected people will have detectable antibodies (Bartlett, 2002: 68).
HIV also has a p24 protein that can be detected four to seven days before the
antibodies appear. Early detection methods include an RNA test that detects
the presence of virus of the blood and can indicate HIV infection ten to fifteen
days after exposure (CDC, 2019f).
Susceptibility to infection and progression of HIV from infection to AIDS
are a function of a number of co-factors. Other STIs, use of recreational drugs
that impair the immune system, malnutrition, other diseases such as tubercu-
losis (TB) or malaria weaken the immune system, or create their own portals
of entry in the case of STIs, and increase the risk for infection. Poverty (which
underlies poor nutrition), the presence of other diseases, and risky sexual be-
havior that includes multiple partners, early age of marriage to polygynous
men, lack of power in or control over decision making, and lack of access to
resources that occur in many nonindustrialized societies also increase the risk
of infection.
HIV infection is classified as AIDS when the immune system of a person
infected with HIV becomes severely comprised. This state is measured by the
CD4 cell count and usually develops eight to ten years after the initial infec-
tion. AIDS requires an HIV positive antibody test (see “HIV testing” section),
and the presence of either a T-cell count of <200 and/or one or more OIs. In
nonindustrialized societies where HIV testing is largely unavailable, inacces-
sible, or fraught with sociopolitical risks for many of the people being tested,
most people find out they have AIDS when diagnosed with an OI (“UN AIDS
2004 Report on the Global AIDS Epidemic 2004,” 2004) (See Table 16.6).
Table 16.6 HIV tests: amount of time needed for accuracy, detection of HIV/AIDS
Name of test Detects HIV How it detects
Nucleic Acid Test After 10–33 days Detects actual virus in the blood. Will give
(NAT) of exposure a positive or negative result based on the
amount of virus present in the blood.
Antigen/Antibody 18–45 days of Detects p24 HIV protein or HIV viral
Test exposure antigens.
Antibody Test 23–90 days of Detects antibodies to HIV in blood or oral
exposure fluid.
Chart developed by Muriel Vernon, Anne Bolin and Patricia Whelehan.
Pre-exposure prophylaxis (PrEP) is a medication that people at very high

risk for HIV take daily to prevent HIV infection. PrEP stops the HIV retro-
virus from taking hold and spreading throughout an infected body. Multiple
studies have shown that PrEP reduces the risk of getting HIV from sex by
404 Sexual Health
99 percent if taken daily and reduces the risk of getting HIV by at least 74
percent in injection drug users (CDC, 2016). Other methods to prevent the
transmission of HIV include condoms, abstinence, and clean needle methods.
Post exposure prophylaxis (PEP) is medicine taken within seventy-two hours
of possible exposure that stops HIV infection. PEP interferes with the path-
ways that HIV uses to cause a permanent infection in the body—going into
the bloodstream as well as the genital and rectal tissues, and preventing the
HIV immune cells from replicating, thus preventing infection from developing
(Arkell, 2018). PEP is not 100 percent effective in preventing HIV infection;
however, research suggests that PEP can reduce the risk of getting HIV by
approximately 81 percent (Centers of Disease Control and Prevention, 2016).
AIDS can be treated, but not cured. Those people who have access to
ARV’s or other forms of anti-retrovirals can experience a strengthening of
their immune system as their T-cell count increases, a reduction of their viral
load (how many particles of HIV are detectable in their blood), and resistance
to OIs. ARVs are expensive, costing between $10,000 and $12,000/year, have
side effects, and must be taken consistently to be effective. The prevalence of
AIDS diagnoses (but not HIV infection) and AIDS deaths have dramatically
decreased with the advent of these drugs in industrialized societies and their
availability to insured, generally middle-class people in the United States since
1996 (“Advancing HIV Prevention,” 2003). Taking these drugs can produce
dramatic improvements in people’s health. However, the efficacy of the drugs
can decrease after about two years for about half the people taking them,
and their availability in the United States is based on political and economic
factors (“Global Challenges: Brazil, Abbott Close to Deal to Lower Price,”
2005; Institute of Medicine, 2001). These include budget cuts to states that
are epicenters of HIV/AIDS, the stigma of HIV/AIDS that makes it a lower
priority for funding than other “lifestyle diseases” such as some heart disease
or many lung cancers, and the overall poorer quality of health and health care
for most of the People Living With HIV/AIDS (PLWH/A) currently in the
United States. Most of these people are poor and of color, African American
or Latino (“Fact Sheet: The HIV/AIDS Epidemic in the US—2005,” 2005).
In non-industrailized societies in sub-Saharan Africa, the Caribbean, and
Southeast Asia that are heavily impacted with HIV/AIDS, people’s access to
prevention, testing, and treatment is determined by politics and economics.
Poverty, stigma, lack of societal infrastructures relative to land, water, and
access to resources that either do not exist or are only available for the elite
in the society, and international trade agreements that concern the kinds,
availability and cost of ARVs mean that the incidence, prevalence, and death
rates from AIDS are high (Desclaux et al., 2003; Jooma, 2006). AIDS is the
end point of HIV infection. People do not die of AIDS per se, but usually
from one or more of the OIs that are ecologically related, and a function of
other diseases in the population and people’s overall state of health. One way
to forestall an AIDS diagnosis and possibly serve as a prevention mechanism
is HIV testing.
Sexual Health 405
HIV Testing
As an intervention effort, HIV testing can be either a prevention tool or the
basis for an initial diagnosis of HIV infection and AIDS. For people who test
negative, education and support about prevention can result in fewer people
becoming infected. For people who test positive, education and support can
occur to prevent transmission to others and to keep themselves from being
reinfected with another strain of the virus. Even further, The START study,
which stands for Strategic Timing of Anti-Retroviral Treatment, completed
in 2015 by the NIH (National Institutes of Health) found that people who
are diagnosed with HIV earlier, and start antiretroviral therapy sooner lowers
the viral load in the blood and reduces the risk that the infected persons will
transmit HIV to others (NIH, 2015). HIV positive pregnant women who know
their HIV status can take anti-retrovirals during their second and third tri-
mesters as well as during labor and birth to reduce the chance of transmitting
the virus to their fetus. After birth, they can reduce transmitting HIV to their
infants if they can bottle feed instead of breastfeed. Bottle-feeding, however,
requires affordable formula, clean bottles, clean water, and a lack of stigmatiza-
tion for not breastfeeding (“Bush’s Global AIDS Plan,” 2004; “UN AIDS Re-
port on the Global AIDS Epidemic,” 2004; “Woman and AIDS: Confronting
the Crisis,” 2004).
There has been an HIV antibody test available since 1985 (Shilts, 1987;
Thomas, 2001). There are three types of HIV tests, which include nucleic acid
tests (NAT), antigen/antibody tests, and antibody tests. NATs analyze blood
samples for the presence of the retrovirus in the blood screen (CDC, 2019).
NAT is also used a molecular technique used for screening blood donations
for HIV infected Blood (Hans and Marwaha, 2014). This technique is very
expensive, but highly sensitive and specific for the viral nucleic acids (Hans
and Marwaha, 2014). This type of testing is only used when the person has
recently had a high-risk exposure or possible exposure with early symptoms of
HIV infection to diagnose (CDC, 2019). The most common test is the antigen
and antibody test. The HIV virus produces an antigen called p24 before the
antibodies develop. There is also an antibody test that detects the presence of
antibodies, and the proteins that a person’s body makes against HIV, but not
HIV itself (CDC, 2019).
Home tests have been available in the United States since 1996. The only
in-home HIV test approved for sale in the United States is the OraQuick in
home test. It is self-administered and consists of a test stick (FDA date needed.).
The kit uses oral fluid to check for antibodies to HIV Type I and HIV Type 2.
The test proves is effective with 92 percent of results that will be positive when
HIV is present and 99.98 percent test specificity of results that will be negative
when HIV is not present.
All fifty states and the District of Colombia require that new cases of AIDs
be reported to the state health department. Only 56 percent of states re-
quired reporting of new persons infected with human immunodeficiency virus
406 Sexual Health
(HIV). There are both anonymous testing, and confidential testing within
the United States. Anonymous testing allows for only a unique identifier to
be attached to the sample and test results. Because there is no way to trace
who had a test, people are protected from the economic, political, and/or so-
cial discrimination they could be subjected to if their test results were known.
However, if anonymous testers test HIV positive, unless they agree to convert
to confidential status, there is no way to provide counseling, medical care, or
other forms of support to them. (CDC testing Laws)
During confidential testing, name and other identifying information will
be attached to the test results, and the test results may go in to your medical
record and be shared with healthcare providers and your health insurance
company. However, it is illegal for these test results to be released without
permission. During confidential testing, if the test result is positive, the name
will be reported to the local or state health department, but all personal in-
formation will not be passed onto the CDC. This procedure is known as man-
datory name reporting. The CDC requires this of States in order to provide
a database of prevalence. States that do not comply with this requirement
risk losing CDC funding. With this database, the CDC determines the need
for interventions from prevention to testing to treatment and allocation of
resources.
Some states, such as New York, also have mandatory contact tracing if
people receive HIV positive confidential test results (but not for HIV positive
anonymous test results). (Remember, there is no way to trace and track some-
one from an anonymous HIV test.) Mandatory contact tracing means that the
sexual and needle-sharing partners of the HIV positive person are contacted
through one of several interventions. The infected person can notify his/her
partners (and this is seen as a “good faith” behavior); someone who works for
the Department of Health can notify the partners, or the HIV positive person
can bring in his/her sex and needle-sharing partners to the HIV test coun-
selor and discuss the situation with the counselor. This is done as a preventive
strategy and is a relatively common public health measure. The concern with
mandatory contact tracing in regards to HIV testing rests with the stigma and
discrimination that still exist for people who are HIV positive. The advantage
of confidential HIV testing is that if people test positive, they can (ideally) be
referred for medical, psychological, and financial care and help. Since anony-
mous and confidential testing have different consequences for people who test
positive, it is important for them to make carefully reasoned decisions about
which form of testing they want.
Both tests require adequate pre- and post-test counseling, informed consent,
and a signed consent form. (Anonymous testers sign with their code number.)
Pretest counseling determines: the window period and the potential risk factor;
type of unprotected sex or risky needle usage; an assessment of how a person
would respond to HIV positive test results; whether the person understands
the difference between anonymous and confidential testing, and whether the
Sexual Health 407
3
person is being tested voluntarily. After all questions are answered and the
consent form is signed, the person has his/her blood drawn. Standard HIV test
results generally are available within two weeks.
HIV test results can be positive or negative, or indeterminate. The first
test performed on the blood sample is an ELISA test. ELISA stands for en-
zyme-linked immunosorbent assay and is a general screening for HIV. If the
blood tests HIV negative on the ELISA, the blood is considered HIV negative.
If, however, the blood tests positive, a second ELISA is performed to ensure
there was no lab error. If that second sample is negative, the blood is con-
sidered HIV negative. However, if the second sample tests positive, a third
test, the Western Blot Test must be performed to provide an accurate result.
ELISAs can detect other viral activity that is not HIV and are designed to test
for more false positives than false negatives. The Western Blot Test is more
discriminating, selecting for HIV specifically. If the blood tests negative on the
Western Blot, it is considered HIV negative. If it tests positive on the Western
Blot, it is considered HIV positive and the person will be told that she or he is
HIV positive. If the blood tests HIV indeterminate, it means that a clear result
is not available. Often, this means that the person is HIV positive, but has
not passed the window period and should consider getting another test later
(Bartlett, 2002, 2006).
Post-test counseling is legally required in order to get test results. In New
York and California post-test counseling and results must be conducted in per-
son; they cannot be given over the phone or to a third party. Post-test coun-
seling involves explaining the test results and discussing ways to remain HIV
negative if that is the case, suggestions of how to proceed if results are HIV
indeterminate, and options if the results are HIV positive. Getting an HIV test
is serious; making the decision to get tested involves a careful consideration
of not only risky behavior and adherence to HIV test guidelines, but an ac-
ceptance of and preparedness to receive HIV test results. There are a number
of controversies and ethical debates in the United States and cross-culturally
about HIV testing, and certain groups are more affected by these controversies
than others. The controversies center on confidentiality concerns and vol-
untary versus mandatory testing. These concerns are most readily seen when
looking at the situation of testing women in this culture and elsewhere.
Since 2003, the CDC has recommended opt-out HIV testing for pregnant
women. Prior to 2003, it recommended opt-in testing for this group. Opt-out
consent means that a test, in this case an HIV test, will be given to pregnant
women unless they specifically decline it. Opt-in consent means that consent
has to be obtained in advance with notification of an HIV test (“Opt Out
Pregnancy” CDC, 2017). It is important to state strongly that women do not
want to be HIV infected and do not want to infect their fetuses and infants if
at all possible. That is not the issue. Why, then, is opt-out testing such a con-
cern? Discriminatory health, social, and legal practices have occurred against
those women who test HIV positive.
408 Sexual Health
• Most HIV positive women in this culture are poor and either African
American or Latina. They fear that they may be blamed for being HIV
infected, encouraged to have an abortion, or be given poor prenatal care
if they refuse to be tested.
• The primary concern is for the fetus in this situation, not the woman’s
health or well-being. This is referred to as a pronatalist stand. With opt-
out procedures, if a woman tests negative, she may not be told her results;
there may not be a discussion about how she can maintain her HIV nega-
tive status, or about her risks for becoming infected in the future.
• HIV testing is supposed to be conducted voluntarily, without pressure,
and with appropriate pre- and post-test counseling. There is concern that
with opt-out testing, the HIV test will be folded in with other prenatal
blood work and that the pre- and post-test counseling will not be done or
will be done incorrectly. There needs to be a separate informed consent
for an HIV test.
• It places the burden of responsibility on the pregnant woman, not her sex
partner. If she tests negative and there is a lack of adequate counseling,
her actual risk for infection is difficult to assess. Since a woman could
be infected at any point in her pregnancy and there is a window period
before antibodies are detected, when and how often are women tested?
Who conducts the test and the counseling? How is confidentiality main-
tained, particularly with reporting claims to insurance companies which
can charge higher premiums or drop clients who have HIV/AIDS?
• Recommendations made by the American Medical Association and the
American College of Obstetricians and Gynecologists are that women
whose sero-status is unknown before she goes into labor be given the Ora-
Quick rapid test when she enters the hospital or birthing center to give
birth. This hardly provides an atmosphere of confidentiality or informed
consent (“Advancing HIV Prevention,” 2003; Banks, 1996; Bennett, 1999).
These concerns are not isolated to pregnant women in the United States. HIV
testing in nonindustrialized societies raises a number of ethical concerns for
women and for men. One concern is confidentiality. United States culture val-
ues privacy, the individual, and confidentiality (i.e., who knows and controls
the release of data).
Cross-culturally, confidentiality may rest with the kin group, or minimally
the women’s male relatives—their husbands and fathers or their brothers—
and not with the women themselves. Women are the focus of testing because
they are the ones who receive prenatal care, have most of the healthcare visits,
and receive most of the contraceptive services in many societies. Research has
found that women are willing to have an HIV test if they can be assured they
will receive the results in a private area, and decide when, how and to whom
results are given (Blankenship, 1999; Coodvadia, 2000; “Women’s Experience
with HIV Serodisclosure in Africa,” 2003). In some sub-Saharan African
groups married couples get tested, but it is usually the husband who makes the
Sexual Health 409
decision about getting tested for both himself and his wife. Decisions about
having an HIV test are serious given that women bear the brunt of HIV care
giving, are usually the ones blamed if they, their partners, or their children are
infected, and are the ones who are most often more severely stigmatized and
ostracized for being HIV positive.
When considering HIV testing outside industrialized countries, there are a
number of factors to consider:
• What does confidentiality mean in this society? Who controls and has
access to information? Who will receive HIV test results and who else
will know?
• Where and how are HIV tests administered? If travel is required to a
health clinic, is the clinic accessible and affordable? OraQuick or other
rapid HIV tests could be helpful in situations where people may only be
able to travel to a clinic once to have a test and need to get tested and
their results in the same visit.
• What are the psychological, social, financial, and political costs of hav-
ing an HIV test? If there are no treatments for those who test positive, if
people lose their employment, are ostracized from family and community,
beaten, killed, or have their children taken from them, is testing appropri-
ate in these situations with the resources available?
• What kinds of community involvement, participation, and education are
there about HIV/AIDS in general, safer sex, and testing? Are local leaders
involved (de la Gorgendière, 2005; Mariano, 2005)?
HIV testing can be a valuable intervention effort. It can serve as a prevention

strategy or as part of getting people into early treatment if they are HIV pos-
itive. However, for it to be effective and safe, the structure and values of the
communities in which people live need to be considered first, resources need
to be available if people test positive, and safeguards need to be in place to
protect people.
Sex and HIV/AIDS

From the information in previous chapters, we know that sexuality is a highly
complex facet of identity that is only further complicated by the existence of
HIV/AIDS. Understanding the fact that human sexuality is a social construct
is necessary in the understanding of the transmission of HIV. According to
the Center for Disease Control, in the United States approximately 91 per-
cent of HIV is transmitted sexually (Centers for Disease Control and Preven-
tion, 2017). Of this percentage, 67 percent of transmission results from male
same sex contact, and the other 24 percent through heterosexual contact. Not
all sexual behaviors are equally as risky. The sexual risk for contracting HIV
exists along a sexual risk continuum. The sexual behaviors that can trans-
mit HIV most easily are receptive anal sex (bottoming), insertive anal sex
410 Sexual Health
(topping), receptive vaginal sex, and insertive vaginal sex. Unprotected oral
sex can transmit HIV, but it is much less risky (less risky does not mean no risk)
(Help Stop the Virus, 2018).
Safer Sex
It is known that some sexual behaviors result in a higher risk of HIV than oth-
ers. Risky sex entails any sexual behavior where people may come into contact
with infected blood, semen or vaginal fluids. To make this type of behavior
safer (i.e., to reduce the risk of transmitting HIV), safer sex can be practiced.
Safer sex includes the proper, consistent use of lubricated, non-spermicidal
internal or external condoms. A female condom (also known as an internal
condom) is a contraceptive device that is inserted into a vagina to help pre-
vent pregnancy, STIs and HIV. External condoms are placed on penises and
also help prevent pregnancy, STIs and HIV. The use of vaginal dams during
oral sex or rimming, as well as the use of finger cots or gloves during anal
and vaginal fingering/fisting also reduces risk for contraction of HIV. This in-
formation can be especially important among sero-discordant couples (one
person is HIV positive, the other HIV negative). Research on these couples
have found that HIV-negative consistent condom users were 71–77 percent
less likely than those who never or sometimes used condoms to acquire HIV
following repeated sexual encounters with an HIV-positive partner (Giannou,
Tsiara, and Nikolopoulos, 2015). In contrast to safer sex, safe sex means there
is no chance of transmitting or contracting HIV between partners. There are a
variety of safe sex behaviors that people can engage in. These include but, are
not limited abstinence, masturbation, fantasy, use of erotica or pornography,
and any sexual behavior that does not potentially expose people to others’
semen, vaginal fluid, or blood are safe sex techniques.
Drugs, Needles, and HIV/AIDS

In the United States, sharing needles or syringes is the second riskiest behavior
for contracting HIV (Centers for Disease Control and Prevention, 2019d). This
means an HIV-negative person uses injection equipment that an HIV-positive
person has used. Needles, syringes and other injection equipment may have
blood in them, and blood is a carrier of HIV. These instances may occur from
injection drug usage, body adornment such as piercing and tattooing, or nee-
dle usage during medical procedures. In the United States, HIV transmission
in healthcare settings is extremely rare, especially since there are number of
control procedures and practices regarding sterilization, disinfection and pro-
tective equipment. In the United States, the blood supply is considered “statis-
tically safe” and the American Red Cross has a number of practices regarding
donation and using new, clean equipment for each blood draw (American Red
Cross, 2004). The risk of HIV from medical procedures in nonindustrialized/
industrializing countries may be higher due to fewer available resources for
Sexual Health 411
sterilization procedures. Medically, the use of universal precautions in which
latex and other barriers are used to keep blood from skin and mucosal surface
contact, and in which needles and other instruments are disposed of in a haz-
ardous waste containers, significantly decreases the risk of HIV transmission
between healthcare workers and patients.
Most of the needle-based transmission of HIV occurs from drug usage. The
United States is considered a drug-using society, as drugs are used recreation-
ally; alcohol, “party drugs” such as ecstasy, crystal meth, and marijuana, as well
as medically in over-the-counter and prescription drugs. Drugs that are often
not classified as drugs, such as caffeine found in chocolate, coffee and tea, are
also used frequently. While drugs are classified as good drugs and others are
classified as bad drugs, much of the risk of HIV from drug use is based on the
effect that a drug can have on judgment, or their effect on certain organs and
the immune system. Directly injecting drugs with needles or syringes that may
contain HIV-infected blood is the second major source of HIV transmission
outside of unsafe sex. When people are under the influence of drugs or alcohol,
they may be more likely to engage in risky behavior such as unprotected sex or
unsafe drug injection. Certain drugs may cause mouth sores or breaks in the
skin that could make transmission of HIV easier.
The reasons that people use drugs and risk HIV infection from drug usage
are varied. Evolution of human neurobiology allows human brains and bodies
to be receptive to chemical substances. Drugs make people feel good, experi-
ence reduced anxiety, pain and fear, and can be an escape from the often-des-
perate reality of some people’s existence. When people become addicted to
drugs, their response to addiction is largely based on the socioeconomic cir-
cumstances of the addict. Middle class, white citizens with health insurance
are more likely to go to a drug rehabilitation program because they can af-
ford it. Their addiction is diagnosed as an illness. Those of lower socioeco-
nomic status and in marginalized populations such as the homeless, African
Americans, and Latinx groups often have their addiction diagnosed as a crime
and are not given equal help to recover.
In order to help reduce the transmission of HIV among individuals using
drugs, needle exchange programs have been created in the United States and
other industrialized countries. These programs are still controversial, as some
believe they enable drug use and injection, and increase taxes and crime for the
surrounding community. However, research indicates that people will change
their needle-using behavior more readily than their sexual behavior, and that
HIV rates do actually decline with the presence of this program (Centers for
Disease Control and Prevention, 2019). The cost of needle exchange programs
is also cheaper than treating a patient with HIV as well, proving it is effective
and cost efficient
Cross-culturally, the highest rates of HIV transmission from drug/needle us-
age occur in parts of the world undergoing rapid economic, political and social
change that are experiencing direct effects of globalization (see Chapter 17).
Kenya, Madagascar, Mauritius, Mozambique, South Africa and Tanzania are
412 Sexual Health
some of the countries with the highest rates of HIV caused by drug injections
(Avert, 2019). In countries where HIV rates are caused by drug injection, there
are often long standing medical and cultural practices that may contribute. For
example, during a war there may be increased drug use due to higher availabil-
ity of injectable drugs and tourist industries. Lack of medical resources during
an armed conflict may also result in higher transmission rates.
Vietnam is a country that experienced a large political and economic ‘ren-
ovation’ that opened new trade deals with countries around the world. After
these changes were made, the use of heroin and the existence of sex work
became more pronounced in their culture (Dao et al., 2013). The young men
using heroin and the women involved in sex work were vulnerable groups,
yet neglected by society (Dao et al., 2013). Tourists began to bring their ideas
about sex and drugs to Vietnam, knowing they were fairly easy to obtain, and
these activities enabled the development of social networks and enhanced per-
sonal economic gain (McKeganey et al., 1998, Stimson and Choopanya, 1998).
This caused HIV rates to rise.
The relative availability of sex and drugs, low prices for drugs, social net-
works that foster drug use, and tourist desire for the exotic, encouraged the
desire and acceptability of drug use in these areas. In earlier stages of the epi-
demic, drug and needle-sharing occurred. Needle sharing fostered rapid trans-
mission of HIV within these drug-using social networks.
Brazil had an HIV epidemic in the 1980s, and at that time 17.3 percent of
cases were due to injection drug use (Guimarães et al., 2015). Most of these
cases, similar to the United States and sub-Saharan Africa, began within the
middle and upper-middle classes, and eventually moved to include those in
lower socioeconomic standings (Andrade et al., 2001). Currently, only 2.1
percent of HIV cases are related to injection drug use (Guimarães et al., 2015).
This reduction stems from a combination of many factors; well-timed imple-
mentation of preventative measures such as needle exchange programs, the
lower quality of street cocaine that made it dangerous and difficult to inject,
the transition to non-injectable drugs, and the violence of drug scenes that
caused high mortality rates among the older cohorts of drug users that favored
injection (Guimarães et al., 2015).
There are a number of factors that affect the success of reducing needle/drug
transmission of HIV. Successful programs outside the United States incorpo-
rate these components:
• They develop programs at grass-roots level.

• They use community and non-governmental groups that take advantage
of human and local resources to implement programs.
• They work with the local law enforcement agencies to establish safe zones
for needle exchanges in areas where needle exchange is illegal.
• They use peer educators and people from the community in education
and outreach efforts.
Sexual Health 413
• They establish programs that meet the linguistic, sexual and economic
needs of the target group.
• They incorporate safer sex messages into harm-reduction models.
• They use harm reduction messages that are less judgmental, more realis-
tic, developed locally and are less authoritarian.
Women and HIV/AIDS

Throughout this chapter, we have mentioned women and their risk for HIV.
Women’s experiences with HIV are unique in many ways. First, they are more
at risk for infection during penetrative sex since they are more often the re-
ceivers. Second, women who have sex only with other women are often min-
imized in the fight against this epidemic, because transmission is less likely
during sex (Centers for Disease Control and Prevention, 2019b). This can lead
to denial of risk, and the number of infected WSW is most likely not accurate.
Third, women face the risk of transmitting HIV to their fetuses or infants
during pregnancy, childbirth or nursing.
Mother to child transmission (MTCT) in industrialized countries specifi-
cally the United States, has been decreasing for decades. From 2012 to 2016,
perinatal diagnoses decreased 41 percent (Centers for Disease Control and
Prevention, 2019), however these cases still disproportionately affected African
American children. There are well-established methods of preventing MTCT,
such as administering antiretroviral drugs (ARVs) to HIV positive pregnant
women and treating the children immediately after birth. In addition, most
HIV positive women in the industrialized nations have the option of safely
bottle-feeding their babies to prevent transmission through breast milk.
However, this reduction in MTCT is not replicated in most of the Global
South where awareness about HIV is less common, and prenatal care and ac-
cess to ARVs by women are irregular at best, and breastfeeding may be the
only or best way to insure an infant survives (Gross et al., 2019). Even if ARVs
are available, it is still possible that the mother may develop resistance to it
(Sanchez and Holguín, 2014).
As a group, women are more culturally suppressed than men, often leading
them to be poorer than men and have worse overall health. In addition, dou-
ble standards of sexual behavior are applied more often and more negatively
to women than to men in most of the world. All of these factors combine to
increase their risk for HIV and the way the virus affects them once infected.
The cultural construction of sexuality generally holds women responsible for
“morality,” and allows them a more narrow range of sexual behavior before
they are ostracized and stigmatized for it. In societies where patriarchal au-
thorities (individuals or families) make decisions for them, women have little
choice or negotiating power about when, with whom or how they have sex, let
alone whether or not to practice safer sex. In addition, there are some areas of
the world that believe having sex with a virgin will prevent or cure diseases,
414 Sexual Health
including HIV/AIDS, which only spreads the disease further. Other practices
such as early marriage of girls, widow inheritance and sexual practices that
leave the vagina dry or irritated can all increase the risk for infection.
Larger political and economic policies that disenfranchise women make
them more vulnerable to infection. Wars, migration, interpersonal violence,
partner abuse, loss of farmable land, and colonial rule that ended women’s
political and economic autonomy all increased women’s dependency on men
and thus their risk for infection. Much of female sex work in global South
societies involves survival sex—the exchange of sexual behaviors for money,
food, shelter and protection for the woman and her family. It is often the only
or best way for a woman to provide for herself and her family (see Chapter 17).
Once infected, women tend to receive less care, experience more discrim-
ination for their HIV status, and die sooner than do men infected with HIV.
Again, poverty, stigma and double standards of sexual behavior (such as
women being blamed for having HIV, having contracted it through “immoral”
behavior and for passing it on to their partners and babies) interact, contribut-
ing to women’s shorter life spans with HIV/AIDS (US Department of Health
and Human Services, 2013).
As noted previously, women all over the world are disproportionately af-
fected by HIV/AIDS, especially women in the global South or in ethnic mi-
norities (Centers for Disease Control and Prevention, 2018). As PrEP has
become a more widely-used means of prevention, women have begun to
take advantage of such advancements, but not to its fullest extent (Centers
for Disease Control and Prevention, 2018). PrEP is highly effective among
women, and it is also a prevention method that the woman herself can con-
trol and administer, without needing their her partner’s consent or cooper-
ation (The Well Project, 2019). As beneficial as this drug can be for women
and for the prevention of HIV/AIDS among their future children, there are
still many barriers to getting PrEP, such as lack of health literacy, high costs
of PrEP, healthcare provider biases and lack of resources/infrastructure to
provide PrEP (Centers for Disease Control and Prevention, 2018). Social and
medical researchers continue to find ways of making PrEP more accessible
to women all around the world, as it may hold the potential to reduce this
international crisis.
Political and Economic Dimensions of HIV/AIDS

Political and economic structures and decisions are inextricably tied to the
risk for HIV infection and intervention efforts to prevent infection and treat
HIV/AIDS. Political decisions in the United States and internationally im-
pact safer sex interventions, access to HIV testing, treatment and stigma.
As with other aspects of the epidemic, the political-economic situations
differ greatly between industrialized, industrializing and nonindustrialized
societies.
Sexual Health 415
The Politics and Economics of AIDS in the United States
In 1996, highly active antiretroviral therapy (ARV/HAART) was introduced,
and it did reduce the number of AIDS cases and AIDS related deaths in the
US. However the HIV incidence rate has not been reduced in the way AIDS
has. From 2012 to 2017, the incidence rate of new HIV cases per year in the
United States remains at approximately 40,000 (Centers for Disease Control
and Prevention, 2019c). Prevention of infection is much cheaper than testing
for and treating HIV disease and AIDS, so why has there not been a reduction
of the incidence rate in the United States? The answer points to political-eco-
nomic factors.
HIV/AIDS was first diagnosed in the United States in 1981 among young,
middle-class, white gay men. Because gay men were a stigmatized group, the
CDC and governmental interventions were slow in responding to this sexually
transmitted disease. President Reagan, at the time, didn’t publicly mention
AIDS until the death of Ryan White, a teenager who contracted HIV from a
blood transfusion and who had been ostracized by his community for having
the virus. AIDS was originally called GRID (gay-related immune deficiency)
which not only minimized the great scale of the disease, but GRID blinded
researchers, healthcare professionals and the public to the realty of the scope
of the disease including the modes of transmission, the individuals at risk and
the communities affected by the virus (Shilts, 1987; Thomas, 2001).
From an activist perspective, middle-class gay men and groups supportive of
them had the resources and political power in some circles to push for research,
development of an HIV antibody test, and treatments. A number of people ac-
tive in the AIDS epidemic believe that if HIV/AIDS had been initially found
among poor, disenfranchised, ethnic and/or female communities, progress
made about the risks for infection, course of the disease, and treatments would
have been even further delayed (Pellowski et al., 2013). Since this first diag-
nosis, great strides have been made towards treatment, reducing levels of dis-
crimination in some parts of the country, and greater awareness of HIV/AIDS
nationally. One of the newest developments of HIV research and treatments is
PrEP, which is used most frequently by men (AIDSVu, 2018). As of 2016, most
PrEP users were also white, showing there are still racial and socio-economic
barriers to accessing this drug for men (Huang et al., 2016).
There is a consistent conversation about AIDS Drug Assistance Programs
(ADAPs) in US government and the funding that it receives. Certain conser-
vative federal administrations have cut funding for ADAPs and advocate for
abstinence-only sex education (now called Sexual Risk Avoidance education).
However, as of 2016, thirty-four states and the District of Columbia require
students receive instruction about HIV/AIDS, but only thirteen states require
that sex and/or HIV education must be medically, factually or technically ac-
curate (National Conference on State Legislature, 2019). As discussed, ethnic
minorities and lower socio-economic classes are particularly affected by these
416 Sexual Health
decisions. Only eight states require that sex-ed programs provide instruction
that is appropriate for a student’s cultural background and not biased against
any race, sex or ethnicity, and only three states require that religion is not
promoted (The Guttmacher Institute, 2020). While these US policies are
discriminatory, the political and economic situation is even more dire in
nonindustrialzied societies.
The Politics and Economics of AIDS Cross-Culturally

In 2016, nearly 53 percent of individuals living with HIV/AIDS were receiv-
ing ART, which was the first time in history that more than 50 percent was
achieved (Kharsany and Karim, 2016). However, most of the people that re-
ceive ART live in industrialized nations. Sub-Saharan Africa is home to only
12 percent of the global population, yet accounts for approximately 71 percent
of the global burden of HIV infection (Kharsany and Karim, 2016). Econom-
ics and politics again play a major role in incidence, prevalence and risk for
infection rates in these areas. Poverty accounts for overall poorer health, com-
promised immune systems, malnutrition and risky sexual behavior for many
people worldwide. These factors comprise major co-factors for HIV infection.
As discussed, women are particularly vulnerable, and their risk extends to the
potential for transmitting HIV to their fetuses and infants.
Societal infrastructures can increase the seriousness of the HIV/AIDS ep-
idemic. These infrastructures may have been impacted by colonial rule or
global markets. There is also a possibility that indigenous healthcare prac-
titioners, engineers and scientists move from their native lands to countries
where the pay, working and living conditions and opportunities for advance-
ment are higher and better than in their home countries (Owusu et al., 2017).
In areas where HIV/AIDS death rates are higher, there may be fewer commu-
nity members available to cultivate new skills and maintain their cultures.
Inter- and intracultural conflict can also deplete populations, drain resources
and increase risk of HIV/AIDS if people are forced to move to other areas or
women are raped as part of the wars (Angel et al., 2018).
Access to drugs and international relief for people with HIV/AIDS in these
situations are also mired in politics and economics. Some countries produce
their own supply of ARVs and generic drugs to assist their own infected pop-
ulations, and may also export to places in sub-Saharan Africa, there is still
an insufficiency of quantity and access to the drugs that would be necessary
meet the needs. While many foreign aid programs originating in the industri-
alized nations aim to assist in the reduction of HIV/AIDS rates, they project
their own Eurocentric ideals onto the programs, neglecting the importance of
community health workers, local religious leaders, congregations, and commu-
nity-based organizations, and thus are ineffective.
In 2003, the President’s Emergency Plan for AIDS Relief (PEPFAR) was cre-
ated as a means of responding to the global HIV/AIDS crisis. PEPFAR works
in fifty different countries to support individuals on ARVs. PEPFAR aims to
Sexual Health 417
purchase safe, effective, quality-assured, and low-cost anti-retrovirals (ARVs)
consistent with applicable international trade law. The use of generic over
branded ARV drugs has allowed the cost of ARV treatment to decrease by
over 90 percent since the beginning of the program. While this program has
been effective in many ways, it still funds programs that teach Sexual Risk
Avoidance education and threatens to defund organizations that do not take
an open stand against prostitution. PEPFAR also does not support needle-
exchange programs, despite their efficacy.
The Socio-Psychological Dimensions of HIV/AIDS

HIV/AIDS is a debilitating situation for the people infected, their loved ones
and their greater communities. The socio-psychological dimensions of this
epidemic include stigma, grief, and loss at the individual, group and societal
level (Asha and Singh, 2017). Stigma itself can be considered a co-factor in
the epidemic. Stigma entails isolation, fear, shame and the assumption of
an identity totally centered on having HIV/AIDS (Fekete, Williams, and
Skinta, 2018). Stigma fuels reluctance to get tested, nondisclosure of one’s
status, ambivalence about practicing safer sex, and prejudice (Mahajan et al.,
2008). Individuals, families and groups all over the world have experienced
stigma and guilt by association from having HIV/AIDS as part of their lives
and communities.
Loss is another aspect of the HIV/AIDS epidemic. The sense of loss is not
only related to the sheer number of people who have died, but to the loss of en-
tire kin groups and communities due to this disease. An estimated 12.2 million
children and adolescents (zero to seventeen years) world-wide had lost one
or both parents to AIDS as of 2017 (United Nations Children’s Fund, 2018).
HIV/AIDS often affects younger people, causing communities to lose people
in the most productive years of their lives, and thus suffer economic hardship
from the disappearance of a large section of the work force (Thomas et al.,
2019; United Nations Children’s Fund, 2018). Opportunistic infections can
leave people disfigured, contributing to a visible loss of bodily integrity and a
further source of stigma as people become thinner, marked with visible lesions
or other physical signs of their illness. Grief is a universal aspect of HIV/AIDS.
There is grief in loss of life, but also the grief that comes with death early
in life. Families, caretakers, and healthcare workers and the larger supportive
communities who tend to the people with HIV/AIDS share the grief. HIV/
AIDS is one of the worst epidemics known to human history.
Responses to the HIV/AIDS epidemic need to be holistic, interdisciplinary,
integrated, and humane. Political agendas, ethnocentrism, and lack of cultural
awareness contribute to the continuation of the disease. Anthropology offers
unique contributions to addressing the problem. Our discipline’s appreciation
of cultural specifics, an emic perspective, and a history of bridging theory and
academic discourse with reality-based and applied activities can serve to re-
duce risk and implement culturally sensitive interventions.
418 Sexual Health
Summary
1 HIV/AIDS is a global health problem.
2 HIV is caused by a retrovirus which eventually destroys the immune
system and results in death for almost everyone who does not receive
treatment.
3 HIV testing can be both a preventive and first-line treatment option. Most
people worldwide do not know their HIV status.
4 Globally, 80 percent of HIV is transmitted sexually, and primarily through
unprotected heterosexual behavior. Women are more at risk for HIV than
are men in any given act of unprotected penile-vaginal intercourse.
5 Safer sex that includes the correct use of lubricated, non-spermicidal con-
doms and other latex barriers can significantly reduce the risk of HIV and
other STIs.
6 Women have become the most at-risk group of people for HIV infection
globally. The reasons for this are biological vulnerability, and social, polit-
ical, and economic policies and practices that place women at risk.
7 Global and local economic and political factors increase the risk for HIV,
including international pharmaceutical and trade practices that perpetu-
ate global poverty and lack of access to ARVs.
8 The socio-psychological challenges associated with HIV/ AIDS include
stigma, discrimination, and grief for those who are infected, their loved
ones and the larger society.
9 Drug-using groups/individuals increase the risk for HIV/AIDS due to un-
safe needle usage that can transfer bodily fluids from one person to an-
other. The potential solutions to this cause of HIV spark large debate
among Americans.
10 The holistic, relativistic, and culture-specific approach of anthropology is
a valuable perspective in responding to the HIV/AIDS epidemic.
1 Why do researchers and activists believe that HIV/AIDS could be the
worst human health problem ever?
2 How do socio-economic, sexual, and political factors affect risk for infec-
tion, HIV testing decisions, and treatment?
Suggested Resources
Books
Shilts, Randy. 1987. And the Band Played On: Politics, People, and the AIDS Epidemic.
New York: St. Martin’s Press.
Vernon, Irene, S. 2001. Killing Us Quietly. Lincoln: University of Nebraska Press.
Sexual Health 419
Videos/Movies
A Closer Walk
And the Band Played On
It’s My Party
Longtime Companion
Philadelphia
Yesterday (HBO)
Websites
CDC. http://www.cdc.gov/. Last accessed 12/30/2019.
HIV GOV. https://www.hiv.gov/ Last accessed 12/30/2019.
Planned Parenthoods. https://www.plannedparenthood.org/. Last accessed 12/30/2019.
UNAIDS. http://www.unaids.org/en/default.asp. Last accessed 12/30/2019.
WHO. http://www.who.int/en/. Last accessed 12/30/2019.
17 Global Aspects of Sex and
Sexuality
Chapter Overview
1 Places globalization in a cultural-historical context.
2 Discusses the globalization of sexuality relative to social, political, and
economic factors.
3 Discusses globalization and sex work/prostitution.
4 Examines the relationship between globalization, sexuality, and HIV.
Globalization
Since the late twentieth century, we have heard a lot about “globalization”
and the “global village.” What do these terms mean and how do they apply to
sexuality? This chapter addresses the globalization of sexuality.
Globalization is a new term for an old phenomenon. It is actually a contin-
uum of centuries of intergroup contact, trade, and change that has occurred
among indigenous groups worldwide as well as between European societies and
traditional peoples since the fifteenth century, including those in the Americas
(Dalby, 2000). For example, precolonial Southeast Asians such as the Macas-
sans from Sulawesi traded with aboriginal people of Northern Australia when
fishing for trepang that they then traded to China (Reid, 1999).
Currently, globalization includes bidirectional contact between indus-
trialized and nonindustrialized societies. Since the late twentieth century,
however, wealthy industrial nations such as the United States, Great Brit-
ain, and Japan have significantly impacted the kinds of social, political,
and economic changes that have occurred. These changes reflect capital-
ism’s influence on the economies of nonindustrialized societies. The ef-
fects industrialized countries have on other countries and groups cannot be
overemphasized.
These effects are global, can be irreversible, and are a definite shift from pre-
vious culture contact and change. Although changing the econiche is part of
human exploitation of resources, there are qualitative differences between how
and what nonindustrialized societies and industrialized societies have done
to and with the environment and one another. For example, the precontact
Mayans overworked the land which resulted in soil depletion. These effects,
however, were local and not global. Industrialized societies have irreversibly
Global Aspects of Sex and Sexuality 421
changed the econiche of rainforests around the world, and have transformed
local economies into sources of production that primarily benefit industrial-
ized societies, not their own (Robbins and Dowty, 2019).
The changes from industrialization are extensive. They range from pollu-
tion that has led to global warming to the destruction of the rainforests in
South America, to control over the production and distribution of drugs by
pharmaceutical conglomerates such as PhRMA (an international drug car-
tel). Changes also include the consequences economic decisions made by the
World Bank have had on small-scale farming. Anthropologists do not see
globalization as a process that creates a uniform middle-class Euro-American
value system worldwide, but instead see it as a phenomenon that engenders
qualitative change. Although these changes primarily benefit those living in
industrialized societies, they do not totally eliminate other societies’ core cul-
tural values. For example, a core value in Latino culture is la familia. La familia
places the nuclear family and extended kin group at the center of daily life.
This value can take on different manifestations depending on location and
degree of assimilation, but it persists.
From the beginnings of the Industrial Revolution in the 1700s to the pres-
ent, globalization has involved the colonization of the people in Southeast
Asia, India, sub-Saharan Africa, and the Pacific. The subsequent indepen-
dence of these groups from colonial rule during the twentieth century does
not isolate them from current international trade and communication or the
effects of capitalism on their local economies. The often-irreversible changes
resulting from colonialism and twentieth-century economic, political, and so-
cial policies extend to sexuality as well. Globalization and the global village
refer to the interconnectedness and expanse of industry, travel, and sexuality
that belie the existence of “purely” traditional behaviors and beliefs almost
anywhere in the world. These concepts are embedded in culture contact and
change, which form the heart of globalization.
Since the late twentieth century, however, the rapidity and nature of culture
contact and change have increased exponentially. This is largely due to the
growth of technology such as computers and the Internet, airline travel with
destinations around the world, the end of European colonial rule, and the
worldwide impact of US foreign policies. The general effects of globalization,
aside from their impact on sexuality, appear in a number of ways:
• A dramatic increase in the variety of food, clothing, art, and cars avail-
able all over the world.
• Outsourcing of work from the United States to nonindustrialized societies
and sweatshop industries in places such as Thailand and India that pro-
vide much of our clothing and other products. Sweatshops exist in both
industrialized and nonindustrialized societies and are characterized by low
wages, unsafe working conditions, long workdays without breaks, and lack
of benefits for the employees (check the labels of your clothes and other
goods to see where they were made!).
• International student exchange programs.
422 Global Aspects of Sex and Sexuality
• The development of generic drugs in Brazil, Thailand, and India, which
are available both in these countries and in sub-Saharan Africa.
• The prominence and influence of the World Trade Organization (WTO),
the World Bank, and PhRMA, which affect world markets.
• “Brain drain,” which occurs when industrialized countries hire profes-
sionals from nonindustrialized countries in fields such as medicine and
engineering. These people leave their homelands, thereby reducing the
number of available professionals in their fields there. The professionals
who leave their home countries may receive lower salaries and benefit
packages compared with the residents and citizens of the hiring compa-
nies (Gender-AIDS e-Forum, 2004/2005; “Global Challenges: Shortage of
Health Workers,” 2006).
• A worldwide increase in tourism, including sex tourism.
These examples reflect both positive and negative effects of globalization and
contribute to it.
Globalization and Sexuality: Trafficking

Globalization also impacts sexuality. In some ways, the globalization of sexu-
ality parallels our previous discussion. International travel, student exchange
programs, commerce, the Internet, media, and migration for work including
the tourist industry or for political asylum all have a sexual component to
them. Although this can have positive results, such as greater tolerance for
diversity and exchange of resources, it can be problematic as with trafficking.
Trafficking is not a recent phenomenon as evidenced by the British and US
“White Slave Trade” scare and laws governing prostitution during the nine-
teenth and twentieth centuries (Fisher, 1997, 2001; Human Rights Watch,
2004; “World AIDS Day,” 2002). Trafficking constitutes a broad range of activ-
ity, although currently most attention is paid to sex trafficking. Trafficking is
largely illegal and refers to the movement of individuals and groups within and
across borders for work that is generally exploitative and underpaid (Farr, 2005;
“Sex Workers,” 2005). Trafficking can involve both children and adults, most
of whom are women; it may be coerced or voluntary; it can entail sex work
as well as sweatshops in factories or indentured servitude in wealthy people’s
homes or businesses (Farr, 2005; Kempadoo and Doezema, 1998).1
In the twentieth and in the twenty-first centuries, trafficking has been
closely related to changes in international and interethnic socio-political and
economic conditions and the resulting migrations of groups. These changes
are global phenomena. Examples of migration include “undocumented work-
ers” who are brought across the US-Mexico border to work in agricultural
and industrial areas, the movement of people from Malaysia to other parts of
Southeast Asia and Asia to find work, the “fall” of the Berlin Wall and the dis-
solution of the Union of Soviet Socialist Republics (USSR), and the changes
in political states in sub-Saharan Africa (Wolffers and Bevers, 1997; Wolffers
and Fernandez, 1999). Economic inequality often leads to migration. It did for
many immigrants who came to the United States from Europe in the nine-
teenth and twentieth centuries, as well as for those who now migrate across
Southeast Asia and in Africa in search of employment. In this chapter, we
are going to focus on how trafficking and larger socio-political and economic
changes have impacted sexuality, particularly sex work as it affects women and
children.
In examining the globalization of sexuality, it is important to understand
how culture contact and change have impacted indigenous sexuality over the
past several hundred years. First, currently there are no cultures that are totally
isolated from industrialized societal influence. What are presented as “tradi-
tional” practices are a function of culture contact and change, colonization,
and industrialization, and this is particularly true for sexual, marital, and fa-
milial behaviors. For example, homophobia and attitudes toward hijras in India
and legal policies toward same-sex sexual behavior are a function of British Co-
lonial law, not of “traditional” beliefs and practices (Kahn, 2001; Nanda, 2000;
“Perspective from India,” 2004). Similar changes can also be seen in China and
Africa (AFROL, 2003; Ruan and Bullough, 1992b; Ruan and Tsai, 1988). In
many sub-Saharan African societies prior to European contact, women had con-
trol over not only their sexuality, but over their profits from market exchange as
well (Setel, 1999). They could refuse sex during menstruation and during the
postpartum period; they kept what they earned in trading. British Colonial law
changed that by transferring women’s economic and sexual rights over to their
husbands and male family members. Consequently, their overall loss of status
and loss of sexual and economic autonomy have resulted in increased risks for
HIV among a number of women in sub-Saharan Africa (Gender-AIDS eForum,
2004/2005). So, in discussing globalization and sexuality, we need to be aware of
both traditional and culture change practices to fully understand its impact. To
do so, we take a deconstructionist approach in this chapter. Deconstructionism
is a way of collecting and analyzing data that challenges androcentric, industri-
alized, etic perspectives while focusing on emic interpretations.
There are highly visible aspects of the globalization of sexuality. They in-
clude multiethnic families and emic and etic controversies over both male and
female circumcision globally. Health care and legal systems are developing
ways to address female migrants who have been circumcised, as well as how to
respond to families who have migrated to industrialized societies and want to
have their daughters circumcised (Boston Women’s Health Collective, 2005;
Stewart and Spencer, 2002). The globalization of sexuality is evident in the
number of Internet pornography sites and the prevalence of sex work around
the world. A Google search of “international pornography” on October 24,
2019, resulted in a list of 60,800,000 sites. For comparative purposes, the same
search in 2005 yielded a list of only 1,730,000 sites.
Sex Work
Sex work is a broad category that encompasses prostitution, pornography,
phone sex operators, exotic dancers (strippers), massage parlor workers, and
dominatrix workers. It includes those services offered over the Internet, those
that occur in brothels, on the street, and through “call work” (Delacoste and
Alexander, 1987; Whelehan, 2001a). Sex work involves males, females, and
transgendered persons, but is primarily engaged in by females. In industrialized
societies, sex work is usually an adult activity; in nonindustrialized societies,
there are more children involved (Farr, 2005; Kempadoo and Doezema, 1998).
The legality and types of sex work found vary widely within and between soci-
eties. For example, pornography by and for adults is legal in the United States.
Prostitution is illegal everywhere in the United States except for counties in
Nevada with fewer than 100,000 people. Prostitution is legal in Canada while
solicitation is not. The “red light” district of Amsterdam, Holland, is well-
known worldwide. Regardless of the legal status of sex work, those who work
in the industry are almost universally stigmatized for doing so, although their
(male) clients experience less stigma (Whelehan, 2001a).
Prostitution is the most common and well-known form of sex work. In the
United States, prostitution is the exchange of sex (left undefined) for money,
goods, or services (goods and services are unspecified) (Whelehan, 2001a).
Since prostitution is the most common form of sex work globally, and 80 per-
cent of sex workers are female, this discussion will focus on female prostitution.
“Prostitution” evokes strong legal, social (moral), and emotional responses from
people. The structure and expression of prostitution are deeply embedded in
larger cultural constructions of sexuality, particularly female sexuality. The cul-
tural construction of prostitution rests on several assumptions about sexuality:
• Sex is defined as largely heterosexual, penetrative, relationship-centered,

and potentially reproductive.
• Sexuality is defined as male: men need and want sex; men are the sexual
beings.
• Male sexuality is defined primarily as sex for pleasure and not primarily
for reproduction.
• Female sexuality is defined primarily as reproductive and not as sex for
pleasure.
• Females are less sexual and more monogamous than males.
When these assumptions are integrated with patrilineal and bilateral descent
(paternity certainty), in rigidly socio-economically hierarchical societies, they
lay a foundation for the existence of double standards of sexual behavior and
female prostitution.
Despite the public noise about sexuality (i.e., its high visibility in the me-
dia, in advertising, in the availability of human sexuality classes), we still
have a very deeply held view that sex is primarily for reproduction. At var-
ious times and in many cultures same-sex sexual behavior, masturbation,
oral sex, and anal sex have all been seen as immoral, deviant, perverse, un-
natural, sinful, or dirty. These behaviors all have two things in common.
They can produce intensely pleasurable sensations without resulting in

reproduction. The brunt of censure for engaging in these behaviors is of-
ten harsher on women who are largely defined by their reproductive ability
than on men who are largely defined by their sexual behavior.
Discussions of prostitution tend to be polarized. Sex workers’ rights groups

advocate for sex work as a form of employment, for clean, safe, and regulated
work conditions, and are against child prostitution and coercion (Delacoste and
Alexander, 1987; Ditmore, 2005; ICPR, 1985; Kempadoo and Doezema, 1998;
Maticka-Tyndale, Lewis, and Street, 2005; “Sex Workers,” 2005). This position
contrasts sharply with most other lay and professional depictions of prostitutes
as victims and deviants and of the act of prostitution as furthering victimization
and deviance (e.g., Farr, 2005). Although there are qualitative and significant dif-
ferences between prostitution in industrialized and nonindustrialized societies,
there are commonalities within sex work/prostitution. These similarities include:
• Sex work/prostitution is primarily a female endeavor.

• The common denominator is money: females can earn more money from
sex work than in “straight” employment that is comparable relative to
their age, education, and skills.
• Prostitution is not the “world’s oldest profession.” It developed from dispa-
rate economic, political, and social conditions that accompanied the de-
velopment of agriculture and agrarian societies (Bullough and Bullough,
1987; Whelehan, 2001a).
• Prostitution did not exist indigenously in foraging and horticultural soci-
eties. Currently, prostitution is global.
• Most of the clients of sex workers are male.
• Prostitutes usually will practice safer sex if they are allowed to with their
clients; as with other people, they tend not to practice safer sex with
spouses and lovers.
The differences, however, between the expression of sex work in industrialized

and nonindustrialized societies are vast.
Sex Work in Industrialized Societies

As a largely female-based endeavor, sex work, specifically prostitution, re-
flects the structure of female sexuality and heterosexuality in patrilineal and
bilateral descent societies where known paternity is important to social and
economic functioning and to reinforcing patriarchy. This applies to both in-
dustrialized and nonindustrialized societies. The expression of female sexuality
and heterosexuality underlies this discussion of prostitution worldwide.
Double standards of sexual behavior are prevalent in many societies, in-
cluding the United States (Crawford and Popp, 2003; Parker and Aggleton,
1997). Men’s sexuality is seen as innate, the norm; heterosexuality is assumed
and unquestioned. In contrast, women’s sexuality is rewarded and accepted
when it is potentially reproductive: in an adult, heterosexual, committed (mar-
ital or other recognized partnership), monogamous, and penetrative relation-
ship (Parker, 2001; Parker and Aggleton, 1997; Parker et al., 1999; Whelehan,
2001a, b). The further from this model the women’s real or perceived sexual
behavior is, the more they are subject to rejection, stigma, and ostracism. The
Latino and Mediterranean concept of machismo illustrates this point. Ma-
chismo connotes virility and the willingness for men to protect their family’s
honor. The idealized counterpart for women is to be “good wives and mothers”
and to be sexually faithful; women desire sex to have children and please their
mates. In societies that have sexual double standards, overtly sexual women
risk having their moral worth called into question as “whores, sluts, and bad
girls.” In gendered social hierarchies, double standards serve to reinforce the
expected sexual behaviors for both men and women, and keep women “in
their place.”
The persistence of double standards, especially for women, permeates the
conceptualization of prostitution. Prostitution provides (male) sexual pleasure
without either commitment or the intent of reproducing legally recognized off-
spring, and disrupts the social order for acceptable female sexuality. Since men are
the sexual beings, female prostitutes are the “bad girls” who undermine the struc-
ture of the (monogamous) family, separating female sexuality from reproduction
and a committed relationship (Thornhill and Palmer, 2000; Whelehan, 2001a).
Given this construction of female sexuality, the predominant view of sex work
and prostitution in industrialized societies is that the women involved could not
consciously choose this work. This view perpetuates the shame and stigma asso-
ciated with prostitution. Stigmatizing sex work maintains the status quo around
female sexuality and heterosexual relationships, perpetuating the “good girl/bad
girl” dichotomy. It keeps women in line, and reinforces men as the people who
need sex and women as the people who provide sex. This model obscures the
economic and political factors underlining prostitution in industrialized soci-
eties and ignores the literature from sex workers’ rights groups (Kempadoo and
Doezema, 1998; Maticka-Tyndale, Lewis, and Street, 2005).
Sex work reflects the political and economic structures of the societies
where it is found. From an activist perspective, sex work challenges the status quo.
International sex workers’ rights groups advocate for sex work to be recognized
as a legitimate occupation (ICPR, 1985). These groups, which include COYOTE
(“Call Off Your Old Tired Ethics”) in the United States; SPOC (“Sex Professionals
of Canada”) and CORP (“Canadian Organization for the Rights of Prostitutes”) in
Canada; and the Scarlet Alliance in Australia, want a number of legal, social, and
political changes to occur. Their efforts are primarily directed toward:
• Decriminalization of prostitution and other forms of sex work globally.

• Clean, safe working environments.
• Prosecution of people who abuse sex workers.
• Health care for sex workers, including drug rehabilitation for women who
exchange sex for drugs or drug money.
• Consensual entry into, involvement in, and exit from sex work.
• Protection of children from recruitment into child prostitution and child
pornography (see also http://www. walnet.org/csis/groups/icpr_charter.html).
Sex workers’ rights groups also work to change attitudes about prostitution.
Even in Holland and Australia where prostitution is legal, workers are stig-
matized. Decriminalizing prostitution, advocating for decent and safe working
conditions, and educating the public about sex work are attempts to reduce the
stigma associated with it, address beliefs supporting sexual double standards,
and challenge the negativity which surrounds women’s sexuality in general.
Patricia Whelehan published an ethnographic study about sex workers who
live and work in urban areas of the United States. The biological men, women,
and transgender individuals in this book made several points about themselves
and their work. First, most of them wanted sex work decriminalized to make it
safer, to promote education about the industry, and to create a legal venue where
abuses can be addressed. Second, most of them found the stigmatization to be
one of the most difficult things for them to deal with as sex workers. The stigma
associated with sex work is what Goffman (1963) refers to as a “master status.” Sex
work defines who and what you are and it also carries over to other areas of your
life. For example, if you are a sex worker, then you must be dishonest, a bad neigh-
bor, wife, and mother. Every aspect of your life is suspect and questioned. Third,
sex workers want to be seen as people for whom their work is one part of their
life, but which does not define them. This is similar to statements made by people
in the lesbian-gay-bisexual-transgender-queer-intersex (LGBTQI) communities.
Fourth, sex workers want their profession seen as a means of legitimate work. The
majority do not see themselves as victims or deviants. Universally perpetuating
the view that they are only adds to the problems they face and reinforces the
sexual double standard (Kempadoo and Doezema, 1998; Whelehan, 2001a).
Finally, sex workers in industrialized societies recognize that they have a
privileged position relative to many prostitutes in nonindustrialized societies.
As such, a number of them work to improve the conditions existing elsewhere,
including changing larger socio-economic situations and advocating for an end
to the exploitation of sex workers globally (Kempadoo and Doezema, 1998).
Sex Work in NonIndustrialized Societies

Prostitution developed from agrarian societies in places such as ancient and
medieval Europe, India, Southeast Asia, China, and Japan. Agrarian societies,
which began 5,000–8,000 years ago, are characterized by hierarchical social,
political, and economic systems that have unequal access to and distribution
of resources. The rationale for inequality in these societies can either be secu-
lar, as in class systems, or religious, as in caste systems. In class-based societies
for example, the ideology embraces upward mobility and “working hard is its
own reward. Anyone can become president if they work hard enough.” This is
referred to as achieved status.
Caste-based societies justify unequal access to authority, power, and re-
sources with such constructs as karma or beliefs in reincarnation. One’s caste
is set at birth and is referred to as ascribed status. In both caste- and class-
based societies, gender is generally perceived as an ascribed status. Historically,
the forms of prostitution found in these societies over the past 5,000–8,000
years reflect not only their socio-economic/political structures, but their be-
liefs about the relationship between sexuality and religion as well. For exam-
ple, prostitution has existed in Europe since the Middle Ages, and was often
found on the outskirts of towns with prostitutes paying tithes to the church
(Bullough and Bullough, 1987). Prostitution in ancient Rome gave us our mod-
ern word “fornication” (sex outside marriage), derived from the Latin word for
the outside structure where street prostitutes solicited customers. In ancient
Greece, the hetarae’s clients were upper-class Greek men. In India, the devi
dasi were sacred temple prostitutes (Bullough and Bullough, 1987). Prostitution
was widespread in other Old World areas as well, such as China, Japan, and
Thailand (Ruan, 1991).
In examining the impact of globalization on sex work in general and pros-
titution specifically, it can be helpful to explore the structure of prostitution
in several societies prior to Euro-American contact. The preindustrial nation
states of China, Japan, and Thailand all had indigenous forms of prostitution.
In China and Japan, both highly stratified societies, men could have a variety
of sexual relationships with women. They could have wives, mistresses, concu-
bines, particularly for the emperors, and patronize prostitutes. In general, pros-
titutes had the lowest status of any of these women, but they were a recognized
sexual contact (Ruan, 1991; Whelehan, 2001b).
China has a rich sexual history. The emperors in particular could have a
variety of and a number of sexual relationships with both women and other men.
Male and female prostitutes were both common and relatively accepted during
the Han dynasty (206 BC–AD 24) (Ruan, 1991). Sex was seen as “a natural need”
to be filled. Taoist beliefs emphasize balance and harmony through yin and yang,
female and male essence, respectively. Prostitutes were believed to balance an
oversupply of male yang with their yin, and thus maintain harmony (Ruan, 1991).
Japan also had geishas. Geishas were not prostitutes but a group of women
who were selected prior to puberty and educated to be highly skilled entertain-
ers. Only a few girls actually became geishas with even fewer becoming owners
of geisha houses, a position of status and respect in Japanese society. Geishas
were conversant and skilled in politics, current events, art, music, dance, the
preparation of Japanese tea ceremonies (an elaborate and time-consuming
ritual), and drama. Geishas’ clients were wealthy Japanese businessmen who
came to the houses to be pampered and entertained. If a geisha had a sexual
relationship with a client, she arranged that independently with him; it was
not an expected part of working as a geisha. These sexual relationships could
significantly increase her wealth and social standing (Golden, 1997).
As a society, Thailand’s views on sexuality are radically different from
Euro-American perspectives. Thailand had an indigenous system of prostitu-
tion dating back to at least the fourteenth century BCE that provided a source
of income to peasant females and served as the sexual initiation for Thai
males (Nadeau, 2005; Seabrook, 2001). Prostitution was a part of Thailand’s
economic structure. As part of the socio-economic structure of a number of
agricultural societies, prostitution also served as a boundary marker for female
sexual morality. Since almost all of the cultures where prostitution existed and
exist are patricentered (focused on the male), and have either patrilineal or
bilateral descent, perceived or known sex outside of a monogamous marital
context exposed women to potential censure as “sluts, bad girls, fallen women,
or whores.”
Contact with Euro-Americans perpetuated indigenous systems of prostitu-
tion, altered the nature of a number of existing ones, and created the economic
environment for it to appear in places where it had not existed previously
(cf. Nadeau, 2005; White, 1990). Colonization changed precontact socio-
economic and political structures, including concepts of sexuality and mo-
rality and sexual relationships (Kahn, 2001; “Perspective from India,” 2004;
White, 1990). These changes particularly affected women in places such as
India and sub-Saharan Africa where British colonial rule altered inheritance,
property, and ownership practices, making women essentially the economic
and legal property of their male kin (Kahn, 2001; White, 1990).
An example from The Comforts of Home: Prostitution in Colonial Nairobi will
illustrate this (White, 1990). Prostitution existed in this area prior to WWII.
Some women migrated to the cities before the war and established comfort
houses that they owned and operated. Comfort houses more resembled what
we consider an inn than a brothel. Men traveling along trade routes found
lodging, food, and company at these comfort houses. Sex was negotiable with
women setting the terms and prices. Often, income from the houses was sent
back to the villages to support the kin group.
When Allied soldiers arrived in Africa, they brought their own ideas of
sexuality and relationships. Over time, these views transformed the nature and
control of the comfort houses. Women were judged by Allied standards of mo-
rality, and the men took over the houses, leaving the women to either work in
them or become street prostitutes. The focus of the houses shifted away from
comfort to sex (White, 1990).
Globalization since the mid-twentieth century has drastically altered pros-
titution. This is most noticeable in what the anthropologist Robbins (2005)
refers to as “peripheral” societies. These societies include the former Soviet
Bloc countries in Eastern Europe, Southeast Asia, and sub-Saharan Africa.
Prostitution in these areas is often radically different from that in industrial-
ized societies for a number of reasons. First, sex work and prostitution in indus-
trialized societies are often a matter of choice, of earning more in sex work than
in other venues. In peripheral societies, it is often a function of economic sur-
vival for the worker and her family. Second, younger females—preadolescent
and early adolescent—are often involved, a practice which is opposed by sex
workers’ rights groups. Third, the stigma associated with Euro-American sex
work extends globally; the stigma attached to prostitution is almost a universal.
Fourth, prostitution frequently accompanies migration in these societies.
Women often migrate within and across borders throughout Southeast Asia,
Malaysia, to the Middle East, from Eastern to Western Europe and in sub-
Saharan Africa only to learn that they can make more money in prostitution
than they can in factories, as domestic workers, or in other venues (Farr, 2005;
Wolffers and Bevers, 1997; Wolffers and Fernandez, 1999). They may also be-
lieve that they have work waiting for them in their new country and find out
upon arriving that the work is coerced prostitution.
Fifth, culture contact and change do not occur in a smooth trajectory
or systematically. What currently appear to be “traditional” sexual mores
and behavior are a result of ongoing contact and change, which have been
transformed into something new and different from either the pre- or early
contact period. As such, sexual expectations between clients and prosti-
tutes can differ radically (Kempadoo and Doezema, 1998). For example,
Seabrook’s Travels in the Skin Trade discusses the expectations that Euro-
pean men have of the female prostitutes they hire in Thailand. Thai women
take “very good care of men,” resulting in their clients “falling in love”
with them. Sometimes clients provide the women with apartments, food,
clothing, jewelry, and cash. The clients become surprised and angry, how-
ever, when the women see the “relationship” as a business relationship. The
women’s loyalties lay with their families. Gifts, money, and other valuables
can be used to support their families, not to fulfill the client’s idea of a “re-
lationship” (Seabrook, 2001), see Table 17.1.
Table 17.1 Sexual tourism
Countries from which sexual tourists depart Sexual tourist destinations
Australia Bangladesh
Canada Brazil
China Cambodia
France Costa Rica
Germany Dominican Republic
Great Britain Hungary
Japan India
Kuwait Indonesia
Norway Kenya
Saudi Arabia Morocco
Singapore The Philippines
Sweden Thailand
United States Vietnam
Source: Adapted from Joni Seager, The Penguin Atlas of Women in the World. London: Penguin
Books, 2003; Martha Ward and Monica Edelstein, A World Full of Women. Pearson Education,
2014.
In Eastern Europe, the dissolution of the USSR and the fall of the Berlin
Wall dramatically affected prostitution in this area. Rapid economic and po-
litical changes accompanied these events; most notable has been the change
of the infrastructure from a communist state where much of the requirements
of daily living such as housing, transportation, food, and medical care are pro-
vided for, to a capitalist market. There has been much political and economic
unrest as a consequence, including the development of an extensive sex trade.
The sex trade in Eastern Europe involves both coercive and non-coercive traf-
ficking within and across European borders as people grapple for economic
survival (Human Rights Watch, 2004; “Sex Workers,” 2005).
Sex work can comprise a specialized form of tourism, sex tourism, where
people travel to specific areas of the world to engage in paid sex. Although
sex tourism exists in various parts of the world, one of the most well-known sex
tourism areas is in Southeast Asia, specifically Thailand.2 Thai attitudes toward
gender, sexual orientation, and age of consent are radically different from in
many Euro-American societies. Coupled with a struggling economy and a strate-
gic geographic location for R&R (rest and relaxation) for United States and East
Asian military personnel stationed in places such as the Philippines, the area is
ripe for a thriving sex industry. Thailand’s sex trade provides incomes for indi-
viduals and their families as well as for the overall economy (Seabrook, 2001).
Sex junkets to Thailand by Euro-American and Japanese businessmen are
popular. Rules about same-sex sex, sex with minors, and “kinky” sex (i.e.,
non-missionary position p-v intercourse or oral sex) are looser than in people’s
home countries or are non-existent. If these sex contacts were truly consen-
sual, were under the control of the sex worker, did not involve minors, and
were protected from HIV and other STIs, there might be less concern about
people’s behavior. However, since market conditions and disposable income
tend to set the working conditions—place, worker age and gender, and be-
havior—there are considerable concerns raised about sexual and economic
exploitation. Since the 1980s, sex workers’ rights groups have consistently ad-
vocated for safe working conditions including enforced safer sex practices and
sex worker input concerning venues and salaries (Farr, 2005; ICPR, 1985; “IXth
International Conference on AIDS in Affiliation with the IVth STD World
Congress,” 1993; “XVth International AIDS Conference (IAC),” 2004b).
A Critical Review of Trafficking

When discussing trafficking as an entity in the context of globalization, much
of the focus centers on prostitution. In some ways, this is misguided. Traffick-
ing involves a number of activities from drugs (think of the cocaine drug car-
tels in South America, Southeast Asia, and Afghanistan) to sweatshop labor
and domestic servitude to coerced child prostitution. Equating trafficking with
prostitution presents several problems.
One, it overlooks the other forms of trafficking, and by doing so does not
address the exploitation and inherent problems in these other activities. Two,
it strongly implies that all forms of sex work are coercive and all sex workers are
victims and exploited. This is often, but not always, the situation as discussed
in the section on sex work in industrialized societies. It also blurs the differ-
ences between sex work in industrialized and nonindustrialized societies, and
diminishes the charter and work of sex workers’ rights groups. Three, equating
trafficking with prostitution presents sex work as the most horrific form of traf-
ficking. That assertion may be arguable when there are six-year-old children
in India and Pakistan who are blind from making finely woven “oriental” rugs
in sweatshop factories. Four, focusing exclusively on sex work perpetuates the
double standard, good girl/bad girl/madonna/whore dichotomies and sex as a
commodity given by women to men. Last, focusing on prostitution and prosti-
tutes as the totality of trafficking does not consider the larger socio-economic
and political conditions that create and perpetuate sex work as it exists in
the twenty-first century. Consideration of these larger conditions is important
when we look at sex work, globalization, and HIV.
Globalization, Sex Work, and HIV/AIDS

Globalization, sex work, and HIV are inextricably linked epidemiologically
and perceptually. As discussed in Chapter 16 HIV is primarily sexually trans-
mitted. Risk for contracting the virus is higher for the recipient than the in-
serter in penetrative sex, which means that men are more likely to transmit
HIV to women than women are to transmit it to men. We’ve also discussed
in Chapter 15 how women’s vaginal mucosa is more vulnerable to the virus
depending on her age, overall state of health, other diseases, and cultural
practices that may tighten or dry the vagina. The common perception is that
women are “the vectors of (HIV) transmission.” However, epidemiological and
statistical studies indicate that women are more often infected by their male
partners than the men are by their female partners (Anderson, 2001; Bailey,
1999; Padian, Shiboski, and Jewell, 1991).
The stigma surrounding sex work extends to and couples with the stigma
surrounding HIV and AIDS. Therefore, female sex workers incur a double
stigma globally: they are sexually “promiscuous” and they transmit disease.
What are the risks for HIV transmission to and by sex workers?
First, not all sex work, just as not all sexual behavior, is equally risky. Phone
sex operators, exotic dancers, and dominatrixes are not at risk for HIV in those
capacities since they do not exchange semen, blood, or vaginal fluids with their
clients. Prostitution involving unprotected anal, vaginal, and to a lesser extent oral
sex are primarily risky to the prostitute since it is her mucous membranes that are
abraded. Making pornographic movies can be risky if the actors do not practice
safer sex. There have been voluntary quarantines and controversy within the porn
industry about risky sex and HIV-infected actors (The Body, 2004).
Generally, if sex workers have the option, they will practice safer sex with
their clients for several reasons. One, it is a good business practice. STIs and
pregnancy are expensive. (Doctor’s visits, medical bills, and antibiotics re-
quire time away from work, a financial investment, and loss of income.) Two,
practicing safer sex provides a physical and psychological barrier between the
prostitute and client. Protected sex is business sex; unprotected sex is lover/
partner/spouse sex. The primary obstacles to practicing safer sex with clients
are financial and political. Clients will often pay more for unprotected than
safer sex. Particularly for women who engage in prostitution as a survival strat-
egy, unprotected sex can mean the difference between paying for food, lodg-
ing, or health care for her and her family.
Socio-political obstacles involve the culturally loaded term “choice.” Choice
is a cultural construct highly valued in the United States. It is not a univer-
sal. Coerced sex work, brothel sex work in which the brothel owners, not the
prostitutes, decide what the working conditions and safer sex practices are, and
survival sex work rarely involve choice. When decisions about sexual behavior
rest with the male kin group or employer, women have very little say over what
happens to them sexually. Before imposing the idea of “choice” onto sexual
decision making, the ability to choose must be present (Farr, 2005).
Sex Work and HIV in the United States

According to Baeten et al. (2005), there is a 0.001 percent probability of female-
to-male HIV transmission for one act of penile-vaginal sex. There is a slightly
higher risk if the female is a prostitute: 0.03–0.08 percent. This statistic seriously
questions the perception of sex workers as diseased and challenges us to look at
the relationship between sex work and HIV in the United States. Emically, sex
workers do not see themselves as responsible for infecting their clients. Depend-
ing on the definition of sex work, this assertion is supported ethically as well. Sex
workers define women who exchange sex for drugs or drug money as substance
users, not sex workers or prostitutes. Women who exchange sex for drugs or drug
money do not necessarily define themselves as prostitutes (Whelehan, 2001a).
Who does then? The answer: the CDC. The CDC does not distinguish between
these emic categories, labeling women substance users who trade sex for drugs or
drug money as “prostitutes” (“HIV Risk Among Persons Who Exchange Sex for
Money or Nonmonetary Items” CDC, 2019).
Blurring emic and etic categories potentially skews statistics and reinforces
stereotypes about prostitutes, disease, and HIV transmission. It can also im-
pact the effectiveness of intervention programs for these women if etic cate-
gories underlie the creation and implementation of prevention and outreach
programs. Statistically in the United States, sex work, when separated from
drug use, is not a significant mode of transmission of HIV from prostitute to
client. The situation in what Robbins calls “peripheral societies,” however, can
be very different (2005).
Sex Work and HIV/AIDS in NonIndustrialized Societies

Where sex workers’ rights organizations and HIV intervention groups have
been able to establish, implement, and support safer sex practices between
prostitutes and their clients, HIV risk is reduced and infection rates fall. This
was clearly demonstrated in Thailand during the 1980s–1990s. A campaign
by groups such as Empower, a sex workers’ rights organization there, encour-
aged clients to use condoms and was highly successful in reducing incidence
rates (“XVth International AIDS Conference (IAC),” 2004; Kempadoo and
Doezema, 1998).
Unfortunately, for prostitutes in much of sub-Saharan Africa, India, China,
and Malaysia, this kind of support generally does not exist. Most of the prosti-
tution in these areas constitutes survival sex and many prostitutes are coerced
into the work (Farr, 2005). Choices are not an option for many female sex
workers who engage in survival sex in nonindustrialized societies. The results
are that these women are then stigmatized and blamed for both the work they
do and as being the source of HIV. Some are forced into sex work after receiv-
ing an HIV-positive diagnosis. Their families and communities reject them for
being HIV positive and “bringing the disease into their homes.” Prostitution
becomes the survival option (Morrison and Fleishman, 2005). Additionally,
these women may have other health issues such as malnutrition or malaria
that act as co-factors for HIV infection. Control over safer sex does not exist
for them, nor do other economic options (Farr, 2005). Literally removed from
their communities by their families, they may be ostracized further for engag-
ing in prostitution. Healthcare options may be less available to them than to
others (Morrison and Fleishman, 2005).
In his February 2019 State of the Union Address, President Donald Trump
proposed a new plan to eradicate HIV/AIDS almost entirely by 2030 (Gon-
salves, 2019. He wants to reduce new HIV infections by 75 percent in five
years, and by 90 percent in ten years. In order to do this, President Trump has
proposed $291 million be set aside in the Fiscal Year 2020 budget. The primary
focus will be taking action such as increased testing, treatment, and offering
pre-exposure prophylaxis in the forty-eight counties, seven states, Washington
D.C., and Puerto Rico in which HIV diagnosis rates are the highest (“Ending
the HIV Epidemic: A Plan for America’?” HIV.org, 2019).
Recommendations to Reduce Risk

To reduce coerced sex work and trafficking in sex as well as the risk for HIV,
larger societal, economic, political, and social beliefs and practices need to
change as well as individual and group behavior. Societies need an infrastruc-
ture of sustainable agriculture or other food sources, roads, water, and health
care. Economically, people need viable sources of income and access to re-
sources. This involves educating girls and providing them with marketable
skills, preventing infectious diseases such as malaria and tuberculosis that
serve as co-factors for HIV infection, and having available a nutritious diet.
Politically, inter- and intragroup warfare needs to be addressed so that the
infrastructure of the society can be maintained and daily life can occur free
from displacement and death. Laws need to change so that economic decision
making/autonomy is returned to women, not left to the state and kin group.
For example, legal protections need to be made for women to be able to go to
school, learn a trade, and keep what they earn from their trades, rather than
turning over their incomes to their male relatives. When their husbands die,
women need to retain their rights to property and their children, rather than
having those rights and her child transferred to her husband’s relatives. Ritual
sexual cleansings of widows can be symbolic rather than behavioral; this will
reduce the risk for HIV infection (Outwater, 1996; Setel, 1999).
Concomitantly, men need to be held responsible for their sexual behavior.
Polygyny and having multiple sex partners can be made safer by educating, en-
couraging, and supporting men in safer sex practices, encouraging later onset
for sexual activity with a partner, and reducing the number of partners. This
can be incorporated into male initiation ceremonies, so that boys enter man-
hood with different ideas about sexuality. Support groups for people who are
HIV positive need to be developed at the grass-roots level, and intervention
efforts need to present accurate information about transmission, HIV testing,
and treatment. These are not new recommendations. The World Health Or-
ganization (WHO) and non-governmental organizations (NGOs) have been
requesting this for more than four decades (“Declaration of Commitment on
HIV/AIDS,” 2001; WHO, 2004a, b; “Woman and AIDS,” 2004).
The risk of HIV for sex workers globally requires an interdisciplinary, ho-
listic, and multifaceted approach. (This is what anthropologists are good at!)
All structures of society are involved: from the individual to group to larger
society, across the life cycle, and encompassing the socio-economic, political,
and symbolic behaviors and beliefs. This entails support or creation of an eco-
nomic and political infrastructure that allows people to survive economically
without putting themselves at sexual risk. Examples of this include village
banking efforts in Zambia that help women economically and also disseminate
health information, and Women Fighting AIDS in Kenya, a grass-roots group
that provides support to home caregivers (Morrison and Fleishman, 2005).
Challenging gender and sexual norms that allow men to be sexual without
responsibility and which denies women their sexuality and ability to say no
needs to occur as well. The approach addresses double standards of sexual
behavior and offers alternatives to risky behavior. Accurate HIV information
and support from NGOs, CBOs (community-based organizations), and FBOs
(faith-based organizations) can help to lessen the stigma around HIV. A holis-
tic approach further supports keeping professionals such as doctors, nurses, and
engineers in their countries of origin and making it safe and feasible for them
to practice there (Gender-AIDS eForum, 2004/2005).
These changes cannot be made by individual societies alone. International
agencies such as WHO, Doctors Without Borders, and the Global Fund to
Fight Malaria, Tuberculosis and HIV continue to work in areas heavily im-
pacted by these problems. The wealthy industrialized societies could allevi-
ate the problems created by globalization if they would critically examine and
change their international business and political practices that contribute to
economic and political disenfranchisement. PhRMA can work with other
countries to make drugs more accessible and affordable. It is not a hopeless
situation, but solutions require concerted, interdisciplinary effort.
In conclusion, globalization is not a recent phenomenon, although the mag-
nitude of commercial capitalism’s impact on nonindustrialized countries has
escalated since the late twentieth century producing irreversible changes in
the environment and the economic lives of people living in nonindustrialized
nations. Globalization is defined in this chapter as bidirectional contact be-
tween industrialized and nonindustrialized nations and does not necessarily
mean that all cultures will become homogenized versions of US society; in-
deed, core cultural features may persist such as the Latinx cultural value of la
familia. However, the influence of industrial capitalism on nonindustrialized
societies is extensive. This has been discussed in this chapter through the
globalization of sexuality and trafficking. Although a broad term, trafficking
generally refers to the movement of people across borders for work that is ex-
ploitative and underpaid. Trafficking is discussed as a product of global eco-
nomic trends that have led to the escalation of migration.
Sex work/prostitution is at the intersection of globalization and sexuality,
and is the emphasis of this chapter. However, it is not the only way that sexual-
ity is affected. In this and previous chapters, we have discussed the exportation
of industrialized versions of homophobia, the change in sub-Saharan African
women’s status that came with colonization, female genital cutting as it be-
comes an international issue through migration, and the expansion of Internet
pornography among other issues impacting women and children specifically.
Because approximately 80 percent of sex workers are female, the emphasis is
placed here on women (and children) as sex workers.
Sex work in industrialized nations and nonindustrialized nations is com-
pared and contrasted. Prostitution/sex work is associated with the develop-
ment of agrarian, stratified, hierarchical societies 5,000–8,000 years ago that
are characterized by unequal access to power, prestige and resources. Sex work
did not occur among traditional foragers or horticulturalists.
Cultural views of prostitution include strong legal, social, and emotional re-
sponses that are embedded in assumptions about sexuality generally and wom-
en’s sexuality in particular. In industrial societies, a double standard of women’s
sexuality is linked to patrilineal and bilateral descent systems, concern with
paternity certainty, and patriarchy as it is embedded in socio-economic in-
stitutions. This double standard is expressed in negative attitudes toward sex
workers who violate cherished notions of women’s sexuality as legitimate only
in the context of a potentially reproductive, heterosexual, committed, monog-
amous relationship. Thus, sex work challenges the status quo. Sex workers’
rights groups advocate for better conditions for sex workers including decrim-
inalization, better working environments, protection of children from recruit-
ment, and de-stigmatization of prostitution among other issues. Sex workers in
industrialized nations are aware that they have a privileged position in com-
parison with sex workers in nonindustrialized nations.
Examples of sex work in preindustrial nation states prior to Euro-American
contact illustrated the various positions of sex workers historically. Patrilineal/
bilateral decent systems in patricentered societies created the dichotomy of
good girl, married woman and the fallen woman, the whore.
The influences of globalization, including colonization, impacted extant in-
digenous systems of prostitution as well as creating the economic conditions
that fostered its appearance in new places, especially peripheral societies such
as the former Soviet Bloc countries, Southeast Asia, and sub-Saharan Africa.
As discussed, sex work in these areas is distinctive from industrialized sex
work in that it:
• Often is not a matter of choice but of survival.

• Often involves preadolescent and early adolescents.
• Has incorporated the stigma associated with Euro-American sex work
conditions.
• Has become global.
• Often accompanies migration.
• Illustrates that culture contact and change do not occur in a smooth tra-
jectory and can create diverse sexual expectations between clients and
prostitutes.
• Can become a specialized form of tourism, sex tourism. Because the mar-
ket conditions tend to set the working conditions, sex tourism raises spe-
cial concerns about sexual and economic exploitation.
A critical review of trafficking argues that prostitution is not the only form of
trafficking in which exploitation occurs. In addition, such a view implies that
all sex work is coercive and overlooks other forms of sex work in industrial-
ized nations where prostitution may be a choice selected from other forms of
work, particularly when viewed from an emic perspective (Whelehan, 2001a).
The current construction of trafficking and the conflation of trafficking with
prostitution perpetuates a double standard, and overlooks the larger socio-eco-
nomic and political conditions that create and sustain sex work as it currently
exists.
Globalization, sex work, and HIV are linked both epidemiologically and
perceptually in a number of ways. Discussion exploded several myths about
HIV, women, and sex work. First, women are more often infected by male
partners than the reverse. Second, sex workers will practice safer sex if they are
given the option or the choice. This comes down to whether women are given
the ability to choose by male kin groups or employers. Data from the United
States indicate that only 0.04 percent of HIV in the United States is trans-
mitted by female prostitutes to male clients. It is important to remember that
clarification of emic and etic categories of sex work is important for statistics
related to prostitution, disease, and HIV transmission.
The evidence of HIV and sex work in nonindustrialized nations suggests
that support for safer sex practices results in the reduction of HIV risk and
infection rates as occurred in Thailand during the 1980s and 1990s. This kind
of support, however, is rare globally and undermined, for example, by the PEP-
FAR plan and its lack of support for condom availability. The gag rule on
international aid agencies that work with sex workers further undermines safer
sex practices.
In order to reduce the risk of HIV for sex workers, a variety of recommenda-
tions are suggested. These include:
• The need for an infrastructure of sustainable food sources;

• Viable sources of income and access to resources, including educating
girls, access to a healthy diet, and prevention and treatment of diseases
that are co-factors for HIV infection;
• Development strategies to enhance women’s status including legal protec-
tions, educational and economic approaches;
• Support of men in practicing safer sex and holding them accountable for
their sexual behavior;
• Development of an interdisciplinary, holistic, and multifaceted approach
that challenges double standards, offers safer alternatives; and
• Reduction of the brain drain of professionals.
This approach includes developing economic and political infrastructures that

allow for economic survival without engaging in risky sexual behavior.
Summary
1 Globalization is an expansion of centuries of intercultural contact and
change.
2 Globalization of the twentieth and twenty-first centuries is primarily di-
rected by the political and economic policies of the wealthiest nations.
3 Globalization impacts sexuality in a variety of ways from changes in dress
and marriage practices to sex tourism.
4 The current HIV epidemic reflects global sexual, economic, polit
ical, and social policies.
1 What changes have occurred in sexuality as a result of globalization over
the past century?
2 How do the economic, political, and social policies of industrialized na-
tions impact sex work in their own and nonindustrialized societies?
Suggested Resources
Books
Farr, Kathryn. 2004. Sex Trafficking: The Global Market in Women and Children. New
York: Worth Publishers.
Kempadoo, Kamala and Jo Doezema, eds. 1998. Global Sex Workers: Rights, Resistance,
and Redefinition. New York: Routledge Publishers.
Robbins, Richard. 2005. Global Problems and the Culture of Capitalism. 3rd ed. Boston,
MA: Allyn and Bacon.
Seabrook, Jeremy. 2001. Travels in the Skin Trade: Tourism and the Sex Industry. 2nd ed.
Sterling, VA: Pluto Press.
Whelehan, Patricia. 2001. An Anthropological Perspective on Prostitution: Mellen Studies
in Anthropology. Vol. 4. Lewiston, ID: Edwin Mellen Press.
Websites
ICPR. International Committee on Prostitutes Rights. https://www.walnet.org/csis/
groups/icpr_charter.html
Child Trafficking. theirworld.org/explainers/child-trafficking.
18 Summary and Conclusion
Chapter Overview
1 Restates the biological, psychological, and cultural perspective, its em-
beddedness in anthropological understandings and how this applies to an
exploration of human sexual behavior.
2 Reiterates the distinction between universal human sexuality and that
which is culture specific.
3 Puts sexual behavior in a socio-cultural context and emphasizes the ef-
fects of culture change on traditional sexual behavior and values.
4 Makes a concluding statement about the potential for changes in homi-
nid sexuality based on late twentieth and twenty-first-century sexual and
reproductive technology.
5 Places AIDS in a global context relative to its threat and the potential for
responding to it in a human way.
6 Places sex work currently in the context of globalization.
An anthropological perspective, including evolutionary, holistic, cross-cul-

tural/comparative, and relativistic approaches, has been used in this explora-
tion of human sexuality. We have framed this as a biological, psychological,
and cultural approach, stressing the interdisciplinary nexus of anthropology
and sexology as well as the multidimensional aspects of human sexual expres-
sion. This approach accents the importance of the individual in society by em-
phasizing her/his relationship to the broader cultural context, yet recognizes
the importance of social systems and cultural meanings in shaping human
sexual experience. We have recognized that a broad lens includes an exam-
ination of human sexuality through space and time as a human phenomenon.
This evolutionary perspective provides a framework for understanding bio-be-
havioral aspects of sexuality as it has developed and changed through time and
adapted to particular environments. It also allows us to explore continuities in
our sexuality through our evolution as primates. Holism allows for examining
sexuality in the context of group behavior and institutions. It relates various
aspects of sexuality such as marriage forms to other dimensions of society such
as the economic and political spheres. Rather than being viewed as separate
Summary and Conclusion 441
from society, sexual attitudes and behaviors are discussed as integrated into
the fabric of the culture.
By aiming for a culturally relativistic or non-judgmental perspective on sex-
uality, the comparative approach can be utilized. Generally, the comparisons
are cross-cultural and international (i.e., inter-societal, but can be extended
to include the higher primates, our closest non-human relatives). Through
a comparative perspective, a better understanding of that which is univer-
sal human sexual behavior (e.g., bonding) and what is culture-specific sexual
behavior (e.g., marriage form) can be achieved. The striking similarities and
rich diversities of human sexuality emerge. These perspectives provide a basic
foundation for exploring continuity and change, our uniqueness as humans,
and the impact that industrialization, globalization, and recent technological
developments have had on sexuality.
As primates and hominids, we have evolved certain bio-behavioral charac-
teristics that affect our sexuality. A crucial characteristic is bipedalism and the
accompanying pelvic and brain changes that affected pregnancy, birth, and sur-
vival of the young. Our young are born immature and have a prolonged infant
dependency on adults. The major human survival strategy is to adapt through
learned behavior. Certain behavioral patterns adapted to specific econiches have
developed to promote reproductive success. These include culture-specific social-
ization patterns, definitions of acceptable sexual behavior, and birth practices.
In the late twentieth century and the new millennium in the United States
and other industrialized cultures, technical developments have become avail-
able which can drastically change our hominid sexuality. Since 1978, the
availability of technological innovations such as in vitro fertilization, embryo
transplants, chromosomal sex selection, sperm banks, and artificial insemina-
tion donor, fetal reduction, and surrogate motherhood have the potential to
qualitatively alter our means of reproduction, alter our definitions of parent-
hood, our concepts of kinship, and of relationships. Most simply, penile-vaginal
intercourse is no longer required for reproductive success. Although societies
have needed fewer adult males than adult females to survive for most of our
evolution, this sex ratio can be altered further with the technical ability to
store sperm indefinitely in sperm banks and to predetermine gender through
chromosomal selection. Amniocentesis and chorionic villi sampling (CVS)
also allow for gender selection in utero. For example, while developed in the
industrialized countries, amniocentesis is used in some societies such as China
and India to select for boys (Ward and Edelstein, 2006).
Paralleling the technological changes are socioeconomic shifts. In the
1950s, in the United States, mostly men worked full-time outside the home
in the labor force while women stayed home (in two-thirds of American fam-
ilies). Currently fewer than 20 percent of all US households practice this ear-
lier twentieth-century traditional arrangement. Dual-career couples are now
the norm. Single-parent families have increased and subsequently leveled off
since the 1970s into the new millennium with the proportion of single-parent
442 Summary and Conclusion
mothers increasing from 12 to 26 percent. Single-parent fathers increasing from
10 percent to 17 percent between 1980 and 2012 (Vespa, Lewis, and Kreider,
2013). There has also been an increase in never-married couples. Among
twenty to twenty-four-year-old women, the proportion of never-married dou-
bled from 36 percent to 75 percent between 1970 and 2003, and never-married
twenty to twenty-four-year-old men increased from 55 percent to 86 percent
in that same timeframe (“America’s Family and Living Arrangements,” 2003.)
The United States has the highest rates of teenaged pregnancy, birth, abor-
tion, and STIs (not HIV/AIDS specifically) in the industrialized world (“Facts
in Brief: Teenagers’ Sexual and Reproductive Health: Developed Countries,”
2006), as well as the fourth highest infant mortality rate of industrialized coun-
tries for newborns. Mexico has the highest rate (“America’s Health Rankings”
2018). Divorce is on the decline in America, falling since the 1980s from 22.6
per 1,000 married women to 17.7 in 2004. Indeed, in 2017 the divorce rate
in the United States had decreased to 2.9 per 1,000 total population (CDC,
2017). But the marriage rate has also dropped by 50 percent from 1970 when
it was 76.5 per 1,000 unmarried women representing a shift from marriage
to cohabitation. As of 2016, about 18 million US couples were in cohabiting
relationships (Stepler, 2017). About 40 percent of cohabiting couples bring
children into the relationship. There are numerous journals, books, and self-
help groups that inform us about how to be attractive, successful, find a mate,
and achieve intimacy. There are a comparable number of books that instruct
us on parenting. Behaviors, values, and courting patterns which previously
occurred in the context of extended kin groups or neighborhoods are now
the arena of sex professionals, educators, counselors, and therapists. Simul-
taneously, industrialized cultures are cognitively more knowledgeable about
sexuality, more openly sexually active, and more openly engaged in lifestyles
including include singlehood, serial monogamy, cohabitation, bisexuality,
and homosexuality.
At the same time that industrialized people are more open about certain
sexual behaviors and lifestyles, we continue to hold rather rigid concepts con-
cerning sexual orientation, gender, and gender role/identity. Concurrently,
however, to balance some of that rigidity in our own culture, a greater inter-
est in the study of sexual orientation and gender identity is occurring in the
scholarly sectors of society. An escalating body of literature on gender vari-
ance cross-culturally is being developed as the internet and tourism introduce
and infuse traditional notions of gender variance with industrialized views of
transgender and broader GLBTQ sensibilities, creating new possibilities and
meanings for gender. The combination of these developments may heighten
our awareness of human sexual diversity and lead us to a more accurate, realis-
tic, and accepting comprehension of identities and orientations.
Human sexuality is further explored from a life cycle developmental context.
Using cross-cultural and industrialized perspectives, attitudes, and behaviors
regarding pregnancy and childbirth, early childhood and adolescence, adult,
and aging sexuality are examined. The bio-behavioral aspects of sexuality are
Summary and Conclusion 443
reinforced through discussions of the universalistic and culture-specific aspects
of these topics as well as human sexual response and birth control.
Globally, we are presented with severe population pressures relative to the
available resources; conflicts between industrialized and indigenous sexual
behaviors and values in acculturating societies and among assimilating indi-
viduals; AIDS, and the increase in sex work and trafficking. Sex work and
trafficking are escalated by globalization and the resultant increase in transna-
tional movement by peoples, as their socioeconomic situations are worsened.
AIDS could easily be our most serious health and sexual problem we face as a
species. The disease has spread worldwide, with devastating effects on the in-
dividuals and groups involved. It may also serve to unite us in our humanness.
Sex work is inextricably tied to HIV/AIDS epidemiologically and perceptually
as well as embedded in assumptions about sexuality generally and women’s
sexuality in particular. Issues such as sex work, trafficking, and AIDS requires
a cooperative, culturally relativistic, and culturally sensitive approach. Studies
on sexual and reproductive health continue to show disturbing trends. Accord-
ing to the World Health Organization, unsafe sex is ranked second of the top
ten health risks, due to the possibility of contracting HIV/AIDS. More than
40 million people currently have the disease (WHO, 2013). However, these
studies are also returning some positive results: there has been a 38 percent re-
duction in maternal mortality between the years of 2000 and 2017. The effect
of HIV on maternal mortality has become less pronounced than it had been
in previous years (WHO, 2019). Additionally, according to the CDC, abortion
rates are decreasing. In 2015, the abortion rate was 11.8 abortions per 1,000
women aged fifteen to forty-four. Between 2006 and 2015, the abortion rate
decreased by 26 percent (CDC, 2015). Unfortunately, though overall abortion
rates are decreasing, unsafe abortions are still prevalent, mainly in industrializ-
ing countries. It was reported that 25 million unsafe abortions were performed
annually worldwide between the years of 2010 and 2014 (WHO, 2019.
As we encounter this evidence of human tragedy and suffering, it has the
potential to elicit from us hominid characteristics such as bonding, flexibility,
and the ability to change and adapt to new surroundings and challenges. In
the past generation, changes in our sexuality are probably as significant to us
now as bipedalism was to our early ancestors.
Human sexuality has evolved over several million years. Its richness, diver-
sity, complexity, and commonality are a reflection of us as a species. Fear, prej-
udice, and ethnocentrism can limit our appreciation of its depth and scope.
Respect, cooperation, and an integration of the cognitive and affective dimen-
sions of our sexual selves may help us to address the challenges we have created
for ourselves as sexual beings.
Notes
Chapter 1
1 We would like to thank Dr. Jane Granskog, Department of Anthropology,
California State University at Bakersfield, for conceptualizing this model. Al-
though it has been modified to meet the needs of our text and been given a new
metaphor, Dr. Granskog was instrumental in providing the foundation for this
approach.
Chapter 2
1 Sue-Ellen Jacobs states in “Native American Two Spirits”: The term “berdache”
[sic] as used by anthropologists is outdated, anachronistic, and does not reflect
contemporary Native American conversations about gender diversity and sexual-
ities. To use this term is to participate in and perpetuate colonial discourse, label-
ing Native American people by a term that has its origins in Western thought and
languages. The preferred term of Native Americans who are involved in refining
understanding about gender diversity and sexualities among Native American
peoples is “two spirit”... or terms specific to tribes (1994: 7). We have adopted
this usage where it seems appropriate to refer to gender-transformed/alternative
genders throughout the Native American ethnographic record and to use the
appropriate indigenous term or the more generic usages such as gender variance
elsewhere.
Chapter 3
1 Some scholars prefer to use the term “hominin” to refer to humans and their ances-
tors (Homo and Australopithecus species) as a reflection of the close evolutionary
similarity of humans, chimpanzees, and gorillas. In this text, however, we will use
the more common and historically older term “hominid” to refer to the group that
includes humans and their ancestors.
2 There are several classical and contemporary theories as to the conditions that
may have led to the development of the visual center of the brain as well as the
grasping hand. Collins (1921) has proposed that binocular vision would be favored
in species that have to leap from branch to branch as in the conditions encoun-
tered by the earliest tree dwellers. Cartmill’s (1974) visual predation theory suggests
that diet may have selected for the grasping hand in tandem with binocular vision
in situations where prey, such as insects, were found on slender vines. Sussman
(1978) is of the opinion that grasping hands would be adaptive for an arboreal
niche where early primates traveled on small branches. In this theory, reliance on
446 Notes
vision occurred because these early primates were probably nocturnal and they had
to be able to locate plant foods in the dark (Ember and Ember, 2005: 77–78).
3 Evidence for large game hunting appears relatively late in human history and may
represent one of several possible strategies for hunting and survival. In fact, mi-
croscopic analysis of the earliest tools dated between two and two-and-a-half mil-
lion years ago reveals that these were not used in actual hunting. Wear patterns
indicate use in modifying plant materials, scraping, and cutting up animal skins
(Zihlman, 1989).
Chapter 5
1 Baldness tendencies are a genetic trait in men carried by females.
2 This does not include taking steroids by some male and female athletes in order to
increase muscle size.
3 Muscle mass and standards of leanness are culturally defined. Men need a mini-
mum of 4 to 6 percent body fat to reach puberty.
4 Sex hormones can stimulate certain cancers.
5 This is not recommended as a means of contraception.
Chapter 6
1 Aspirin dissipates prostglandins. It also is an anti-clotting agent. If a woman has
blood clotting disorders or is to undergo surgery, she should limit her aspirin intake
and inform medical personnel as to how much and when she last took aspirin.
2 The craving for chocolate may be related to phenylethylamine. One of its chemical
compounds is related to phenylalanine, an amino acid. These compounds may
serve as mood elevators in humans.
3 Currently, regulated sperm banks test donations for HIV, since the virus is carried
in semen.
Chapter 7
1 It takes about twenty-four to thirty hours to replenish the supply of sperm after
ejaculation (Stewart et al., 1979).
2 Medical terminology for various sexual and reproductive conditions frequently has
pejorative connotations. These connotations, while not consciously intended to
hurt clients, may inflict psychological and emotional discomfort or harm a client.
A distraught, infertile couple does not need to hear about “hostile” cervical mu-
cous or “incompetent” cervices in their attempt to remedy their situation.
3 As of 2005, the FDA (Food and Drug Administration) requires that AI-D dona-
tions are screened for HIV, since the virus is carried in the semen of an infected
person.
4 The role of H-Y antigen in male sexual differentiation is controversial.
5 Later differentiation may occur in the female so that Wolffian duct development of
the urinary tract can take place.
6 They have been referred to as “degenerate testicles.” See note 2.
Chapter 9
1 This is incorrect/outdated. In fact, approximately 60 percent of practicing obste-
trician-gynecologists in the US and Canada are female and about 80 percent of
residents in OB/Gyn are female.
Notes 447
https://www.sciencedaily.com/releases/2019/04/190401115815.htm
ht t p s://w w w.npr.or g /s e ct ion s/ he a lt h-shot s/2018/0 4/12/596396698/
male-ob-gyns-are-rare-but-is-that-a-problem
2 Even the term “coach” implies some form of external management akin to an ath-
letic event.
Chapter 10
1 The interested reader is encouraged to explore the works of Cohen (1978), Fox
(1980), Levi-Strauss (1969), Livingstone (1969), Murdock (1949), Phelan (1986),
and White (1948), among others too numerous to mention. Recent reviews of the
incest taboo include Meigs and Barlow (2002: 38–49), and Patterson (2005: 1–18).
Chapter 12
1 The meanings that sex is given in a society are embedded and expressed in com-
plex ways through the social structure and the ideological system. For example,
how people experience their sexuality is linked to the ideological system such as
beliefs about reproduction, menstruation, and pollution. All are part of shaping
sexuality at the personal and cultural level. Indeed human sexuality “is embedded
in a complex web of shared ideas, moral rules, jural regulations, obvious associa-
tions and obscure symbols” (Davenport, 1977: 117). Our sexuality is ultimately part
of “worldwide economic, social, political and cultural systems” (Ross and Rapp,
1983: 57) which have diverse histories, trajectories and encounters (Herdt, 1999,
2004). The ethnographic spectrum offers an array of sexual practices and beliefs
that are testimony to the flexibility of humans in their ability to adapt to different
cultural milieus and environments.
2 Anthropologists have also devoted considerable time and increasing attention to
studying sex in industrialized societies.
3 This may be contrasted with Judaic traditions that have a generally positive view
of sex regarding it as a gift from God if practiced in the appropriate moral context
(Stein, 2005).
4 Faludi’s (1991) research challenges an earlier statistic that women’s disposable in-
come after divorce drops almost 73 percent (AAUW, 1989: 5).
Chapter 14
1 Additional information on homosexual support groups and referral sources for
gays, lesbians, their friends, and loved ones can be obtained from the Lambda
Legal Defense Group, Lambda Rising and PFLAG. These groups have chapters
around the country.
Chapter 15
1 Transgender has several meanings within (emic) and outside (etic) the gender
variant communities. Your authors recognize the different connotations associated
with the transgender identity and transpeople.
Chapter 16
1 GRID (Gay-Related Immune-deficiency Disease) was a misnomer that reflected the
homophobia and sex phobia of the media, researchers, and the Centers for Disease
448 Notes
Control and Prevention in 1981. That misnomer created the perception and belief
that HIV/AIDS was a “gay” disease, something that has persisted among a number of
groups to the present and which also contributed to the stigma associated with it.
2 The Centers for Disease Control (CDC) have been renamed the Centers for Dis-
ease Control and Prevention. As of July 1993, the commonly used acronym for this
organization remained the “CDC” and will be used here. Statistics are updated
biannually by the CDC.
3 Mandatory testing is required to enter and stay in the military, to be in the Job
Corps, and can be court-ordered in the United States. Mandatory testing was pro-
posed by some members of Congress in the 1980s with quarantine recommended
for those testing positive. That did not occur.
Chapter 17
1 As controversial as discussions of trafficking are, it is important to remember that
what constitutes childhood and adolescence are culturally defined.
2 One of the major concerns with sex tourism is the coerced and exploitative nature
of it particularly for women and children. Here are URLs for two groups that specif-
ically address sex tourism, trafficking, and children: http://www.childrentrafficking.
com and http://www.ecpat.net/eng/index.asp.
Glossary
A-frame orgasm An orgasm occurring as a consequence of stimulation of

the Grafenberg spot.
abstinence For this book’s purpose, the practice of refraining from anal, oral,
and vaginal intercourse.
acculturation The change that occurs in the original culture when two or
more cultures are in contact with each other.
achieved status One’s rank in society based on one’s efforts.
actual effectiveness rate The statistical figure used to calculate accuracy in
birth control. Since not all couples use birth control properly or consis-
tently, this figure will be lower than the theoretical effectiveness rate.
acute aspects of disease Sudden onset and relatively rapid course of infection.
adaptation “The process by which organisms achieve a beneficial adjustment
to an available environment, and the results of that process” (Haviland,
1989 59). In evolutionary theory, referring to the principle that traits
arise through natural selection.
adolescence The period of life from puberty to maturity terminating legally
at the age of majority.
adolescent sterility The period that occurs between menarche and repro-
ductive maturity when pregnancy is not likely to result from intercourse.
It has been discussed among the Ju/Wasi people as a mechanism for con-
trolling population.
adrenal glands Two small glands located on top of each kidney that are re-
sponsible for much of the other sex hormone production in males (proges-
terone) and females (testosterone).
affinal kin/ties/relations Those individuals who are related by marriage. For
example, “in-laws” in US culture.
age of maturity A marker established by Euro-American society where an
individual gains the legal status of adulthood, conferring both rights and
responsibilities. These include marriage, adult responsibilities for criminal
actions, and the right to make personal choices.
age set A “non-kin association in which individuals of the same group inter-
act throughout their life” (Oswalt, 1986: 432).
age-grade A grouping of individuals based on shared biological maturity. It
includes responsibilities, rights, cultural practices, and obligations that
change from age stage to age stage.
450 Glossary
AIDS (Acquired Immunodeficiency Syndrome) The latter stages of HIV
infection characterized by a positive HIV antibody test, and/or low or ab-
sent T-cells, and one or more opportunistic infections.
AIDS Drug Assistance Program (ADAP) Federally funded programs that
help PLWH/A be able to buy ARVs.
alliance theory Theory that exogamy creates economic and political rela-
tionships between groups, some of which might otherwise be in conflict
and/or forges broader social networks and economic ties providing greater
integration.
alloparenting Use of extended kin and non-kin as a means of socioeconomic
support and socialization of children as a continuation of our hominid
behavior.
ambilineal descent The tracing of one’s family through either the male or
female parent or both.
amniocentesis The surgical insertion of a hollow needle through the ab-
dominal wall and uterus of a pregnant female, especially to obtain amni-
otic fluid for the determination of sex or chromosomal abnormality.
amnion The bag of waters surrounding the embryo.
ampulla The far end of the fallopian tube.
anal stage Freudian psycho-sexual stage of development occurring at approx-
imately two years of age when the child achieves control of bladder and
anal sphincter and finds pleasure in this sensation.
analogous/analogues Something that is similar in function to something else.
anatomy Study of specific body parts or structures.
androcentric Sexist, male-biased.
androgen insensitivity syndrome The most common hormonal error that
occurs in chromosomal XY males. The testes secrete amounts of testos-
terone that are generally defective so that these cells are unresponsive to
testosterone. The fetus develops with partially feminized sex hormones.
androgen(s) The hormones such as testosterone and androsterone that pro-
duce or stimulate the male characteristics.
androgynous gender role On the scale of traditional, non-traditional, and
androgynous gender roles can roughly be conceptualized as a fluid contin-
uum with traditional and liberated (i.e., non-traditional) as more opposed
than symmetrical to each other, and androgynous as comprising a wide,
gray mid-section.
androgyny/androgynous Greek word combining words for male, andros, and
female, gyne. Refers to responding to the situation regardless of one’s gen-
der or gender-defined characteristics.
andropause A male counterpart to menopause that has recently been iden-
tified and “named” in late twentieth-century Euro-American scholarly
and media discourses. This has been variously designated as the male cli-
macteric, male menopause, and/or andropause.
anonymous HIV testing Number coding for an HIV test where the person
is only identified by a number, and no name is given.
Glossary 451
anorexia nervosa Severe and dangerous eating disorder that is found primar-
ily in middle-class adolescent females and that involves minimal intake of
food and that can cause the cessation of menstruation and other health
problems.
anthropology The interdisciplinary approach that studies human and pri-
mate behavior evolutionarily and across cultures through the examina-
tion of paleo and archaeological data as well as the interaction of people
in modern human groups.
anti-retrovirals (ARVs)/anti-ret medications Also referred to as HAART
(highly active antiretroviral therapy). Those drugs given to people with
HIV/AIDS to decrease their viral load, boost their immune systems
(T-cells), and prevent opportunistic infections.
arboreal Adapted to life in the trees.
areola Pigmented area surrounding the nipple.
arousal phase Kaplan’s combined term for Masters and Johnsons’s excite-
ment and plateau phase.
artificial insemination by donor (AI-D) The use of ejaculate from a per-
son other than the woman’s husband or significant other to medically
inseminate her. Generally done when the woman’s partner produces no
or insufficient or problematic sperm to be able to impregnate his wife/
significant other.
artificial insemination by husband (AI-H) The use of the husband’s ejacu-
late to medically inseminate his wife. This may be done for psychological
reasons or when the husband’s sperm is of low quantity and multiple ejac-
ulate samples are concentrated and injected into the vagina.
ascribed status One’s rank in society based on birth or biological
characteristics.
Assisted Reproductive Technology (ART) Any technology that increases
the chances that conception will occur and the baby will be carried to
term.
associated polyandry The practice where a woman is allowed multiple re-
lated husbands. These men are referred to as “visiting husbands.”
attractivity A term proposed by Beach (1976) to describe aspects of female
sexual behavior that refer to males’ interest in mating with females.
autogynephilic Transsexuals (male-to-female) who are sexually attracted to
women.
autonomy theory Reiss’s theory that sexual permissiveness will increase
in cultural contexts in which adolescents have greater independence in
courtship and dating.
avunculocality Unmarried couples’ residence with the mother’s brother.
Barrier Method Contraceptive method that prevents pregnancy by placing
a barrier between the egg and sperm so the sperm cannot reach the egg
to fertilize it.
Bartholin’s glands Located at the base of the introitus, these glands secrete
a clear liquid whose function is unknown.
452 Glossary
basal body temperature The body temperature at rest, usually taken before
arising in the morning. Used to determine when a woman is ovulating
and therefore may be used as a method of birth control.
berdache Term used in early anthropological literature. It is no longer used
and is a misnomer.
bi Term used for those whose sexual and romantic interests are in people of
their own and the opposite sex.
bilateral descent (non-unilineal, double descent) The practice of tracing
one’s descent through both parents with each lineage in control of differ-
ent areas of activity and property.
bilateral kindred (kinship) The system of kinship structure in which an
individual belongs equally to the kindred of both parents.
bilineal descent Similar to ambilineal type in which descent is traced
through both the patrilineage and matrilineage with each controlling dif-
ferent areas of activity and property.
Billings method Birth control rhythm method based on evaluation of vagi-
nal mucous to determine when ovulation takes place.
bilocality Practice where the newly married couple may live near the bride’s
or groom’s parents and follow the particular set of rules established by
either the parents or the culture.
bio-cultural An anthropological approach that incorporates an understand-
ing of humankind as both biological and cultural beings.
biological reductionism The theoretical approach that reduces and inter-
prets behavior to its biochemical and genetic basis.
biological relations (consanguineal) Kin related by descent or filiation
rather than through marriage; “blood relatives.”
biological sex Generally considered the definition of one’s sex as male or
female but includes chromosomal, gender, hormonal, internal reproduc-
tive structures, sex characteristics, gender identity and role assignment
and rearing, and legal sex.
biological, psychological, and cultural approach Includes such fields as
medical anthropology, biological anthropology, the anthropology of sex
and gender, psychological anthropology, and clinical anthropology.
bipedalism The ability to maintain and walk in an upright position.
birth attendants Those people, often women in traditional societies, who
stay with a pregnant woman during her labor and birth.
birth control Methods used to prevent conception and control fertility.
bisexual Sexual and romantic attraction to people of your own and the op-
posite sex.
blended family A household made up of two parents, their biological chil-
dren, and any children from previous marriages and other relatives.
blended orgasm Combines characteristics of the vulval and uterine orgasm.
blood ties Blood relations; refers to those people related to you genetically,
also referred to as consanguineal kin.
body fat The amount of fat located beneath the skin.
Glossary 453
bonding The ongoing and continuous socio-emotional link between people.
brain complexity Human reliance on learning is a significant aspect of our
sexuality associated with the expansion of the neocortex.
brain drain Hiring professionals from nonindustrialized societies for posi-
tions in industrialized societies, resulting in a lack of professionally trained
people to attend to the needs of their home country.
breastfeeding Feeding an infant from the milk produced by the mammary
glands of mammals.
broad ligament A band of connective tissue across the lower abdomen that
supports the uterus, fallopian tubes, and ovaries.
calendrical method Based on a formula in which eighteen is subtracted from
a woman’s shortest cycle and eleven from her longest cycle observed over a
minimum of eight cycles with day one being the first day of menstruation.
castration Surgical removal of the testicles or chemical removal of the an-
drogens produced by the testes.
caul The amnion or “bag of waters” that envelops the developing embryo/
fetus.
CC + HPG axis Biochemical basis of human sexuality.
Centers for Disease Control and Prevention (CDC) The organization that
tracks the incidence and prevalence of diseases within the United States,
and makes recommendations about their prevention and treatment.
cerebral cortex (CC) The outer layer of the brain characteristic of humans
and hominids involved in perception, analytic and logical thought, and
learning.
cervical cap A barrier method in which a small plastic or rubber cup is
placed on the woman’s cervix and which must be used in conjunction
with spermicides.
cervical mucous checks Birth control based on avoiding sexual intercourse
during the time when the cervical mucous thins in order to allow sperm
to pass through the os.
cervical mucous A thickish, sticky substance that covers the os prior to ovu-
lation. At ovulation, the cervical mucous thins and stretches, allowing for
sperm to pass through the os into the uterus.
cervix The lower section of the vagina.
childbirth The bio-social process where a woman experiences labor and the
expulsion of the fetus from the uterus.
chorion The structure that eventually develops into the placenta. The cho-
rion secretes hormones during the early stages of pregnancy that allow it
to attach to the uterine wall and which are detected in pregnancy tests.
chorionic villi sampling (CVS) A technique for diagnosing medical prob-
lems in the fetus as early as the eighth week of pregnancy; a sample of the
chorionic membrane is removed through the cervix and studied.
chromosomal filtration Method of preselecting XX or XY chromosomes.
chromosomal sex Also referred to as genetic sex, it is sex determined at con-
ception, either XX for a girl or XY for a boy.
454 Glossary
chronic aspects of disease A medical condition that is incurable and can
affect people’s functioning but may be treatable.
circumcision In the female, surgical procedure that cuts the prepuce expos-
ing the clitoral shaft; in the male, surgical removal of the foreskin from
the penis.
clan A group of people whose unilineal descent is established upon a belief that
they have a common real or mythical ancestor even if the claim cannot be
proven. While biological links cannot be traced due to the large number of
people concerned, the group shares mutual economic security, social control,
political and marriage relations, religious practices, and ceremonies.
climacteric Sexual aging experienced by both men and women including
physical and social change.
clitoral hood In the female, the upper part of the labia minora that covers
the clitoral glans.
clitoridectomy Surgical removal of the clitoris practiced in some cultures.
clitoris A female sexual structure involved directly or indirectly in sexual
response that is homologous to the glans of the penis.
co-factor A variable or other infection/disease/health status that can in-
crease one’s risk for HIV infection.
cognatic descent The practice of tracing relations through both sides of the
parental lineages (i.e., non-unilineal).
coital The physical union of male and female genitalia accompanied by
rhythmic movements (i.e., insertion of penis and vagina in heterosexuals).
coitus interruptus A method of birth control in which the penis is with-
drawn from the vagina prior to ejaculation.
Community-Based Organizations (CBOs) Those groups that are derived
from, located in, and serve specific communities.
competence What a person knows, both consciously and unconsciously,
about her or his culture.
comprehensive sexuality education Education that includes information on
a variety of options over abstinence-only education.
conception The union of the sperm and egg.
conceptus The fertilized egg.
Confidential HIV Testing HIV testing in which a person’s name is recorded
and known but kept private.
confinement The period surrounding labor and birth when a woman’s activ-
ities are restricted.
consanguineal (kin/ties/relations/family) Kin related by descent or filiation
rather than through marriage; “blood relatives.”
contraception Any natural barrier, hormonal or surgical means, that pre-
vents conception and pregnancy.
coronary heart disease (CHD) Blockage of the arteries to the heart that
increases the chances of a heart attack.
corpora cavernosa Hollow, spongelike cylinders of tissue within the penile
shaft that become engorged with blood during sexual excitement.
Glossary 455
corpus luteum Reddish yellow endocrine tissue that forms within a ruptured
ovarian follicle. It produces progesterone.
corpus spongiosum A spongy cylinder of tissue running through the un-
derneath part of the penis shaft that also becomes engorged with blood
causing erection.
corpus The body of the uterus composed of several layers including the
endometrium.
couvade The couvade is a culturally created bio-behavioral phenomenon in
which the father shares pregnancy prohibitions and restrictions with the
woman who is bearing his child.
Cowper’s glands Located beneath the prostrate on either side of the ure-
thra, their secretions neutralize urine acid levels and lubricate the urethra
during the emission (first stage) of ejaculation.
cremasteric muscle A muscle located in the spermatic cord that elevates the
testicles when contracted.
cremasteric reflex The response of the cremasteric muscle.
cross-cousin A relative who is the child of one’s mother’s brother or father’s
sister.
crura The innermost tips of the cavernous bodies that connect to the pubic
bones.
cuckolded Generally applies to a man whose wife has had sex with someone
else.
cultural constructionist/constructionism The examination of human be-
havior as a function of socio-cultural factors.
cultural relativism The concept that cultures operate within their own
structures, values, beliefs, and symbols and that they are to be interpreted
within that system.
cultural system Patterned beliefs and meanings.
culture lag A situation that occurs when behavior changes faster than the
belief system.
culture The learned behavior, skills, attitudes, beliefs, and values of a par-
ticular society. These are learned by observation, imitation, and social
learning.
culture-bound Unique to a given culture.
cunnilingus Oral stimulation of the clitoris, vaginal opening, or other part
of the vulva.
cyclic/cyclicity The term used to refer to the female’s pattern of hormone
release during her reproductive life cycle.
cystitis A non-sexually transmitted infection of the urinary bladder.
deconstructionism/ist An approach to collecting and analyzing data that
challenges etic, androcentric, industrialized perspectives and focuses on
emic perspectives.
Depo-Provera Hormonal birth control method in which injectable syn-
thetic progesterone prevents the release of the ovum and interferes with
implantation of an egg in the uterus lining.
456 Glossary
descent group A set of relationships that cannot be changed by location or
death.
descent theory Endogamy as a vehicle for families to contribute to cohesion
and solidarity by keeping wealth, power, and prestige within the group.
descent The tracing of one’s relationship based on the parent/child connec-
tion that defines the social relationship. Often claims are based on com-
mon ancestry that may or may not actually exist. Descent may be based
on the mother’s, father’s, or both parentage.
desire Precursor stage to arousal; specific sensations that lead to an interest
in having sex.
developmental level Also known as the ontogenetic level of the three cate-
gories of explanation. This level causes external and internal experiences
in the individual’s lifetime.
Diagnostic and Statistical Manual of Mental Disorders (DSM) Published
by the American Psychiatric Association, this handbook is used most of-
ten in the diagnosis of mental disorders in the United States.
diaphragm Thin dome-shaped barrier that prevents sperm from entering the
cervix that is used with a spermicidal gel or cream.
dilation and evacuation (D & E) Abortion method that combines the vac-
uum aspiration method with elements of dilation and curettage.
disease The physical manifestations of being sick or having been infected
with some microorganism.
division of labor The basis on which work is decided, often by sex or gender.
dorsal lithotomy position A position that is common in US obstetrics and
used during pelvic exams where the woman lies on her back with her legs
apart and her heels resting on an elevated surface.
double descent (non-unilineal, bilateral descent) The practice of tracing
one’s descent through both parents with each of these in control of differ-
doula(s) Adopted from the Greek, doulas are women who provide socio-psy-
chological support to women during pregnancy and the postpartum
period.
“down low” The term used in the African American community to refer
to men who have sex with men covertly, but do not practice safer sex or
inform their female sex partners of their behavior.
Down’s Syndrome A chromosomal abnormality that can result in the birth
of a child with cognitive and other physical problems.
duolocality The living arrangement where a young married couple lives
apart from one another so only blood relations make up a household.
dysmenorrhea Painful menstruation.
dyspareunia Painful intercourse for women.
econiche A particular environment to which a species is adapted.
ectopic pregnancy The implantation of a blastocyst somewhere other than
in the uterus, usually in the fallopian tube.
effacement The gradual softening of cervix during labor.
Glossary 457
ego The term used for a person or persons in determining and tracing kinship.
ejaculate A substance containing semen, sperm, and other chemicals that
aid in sperm transport and mobility.
ejaculatory duct/tract Continuation of the vas deferens through the pros-
trate to the urethra.
Electra complex The female version of the Oedipal complex. The young
female sexually desires her father and thus regards her mother as a
competitor.
ELISA (Enzyme-Linked Immunosorbent Assay) A general screening test
for HIV.
embryo transplants Procedures in which a woman other than the prospec-
tive mother is impregnated with the husband’s sperm. After several days,
the fertilized egg is removed from her womb and placed within the moth-
er’s uterus.
embryo Term used to refer to the fertilized egg after it implants in the uterus
until the end of the eighth week of pregnancy.
Emergency Contraception (EC) A form of post-coital contraception taken
within seventy-two hours of unprotected p-v intercourse that prevents
conception (e.g., morning-after pills).
emic The perception of a phenomenon as seen and felt by a participant in-
side the system.
endemic warfare A practice of ongoing, ritualized conflict between horticul-
tural groups that compete for limited resources.
endemic A disease that is well-established in a population.
endocrine glands Glands that directly release hormones into the blood-
stream. Sex hormones are released by endocrine glands.
endogamy The rule that requires a member of a community to marry within
their group, tribe, caste, or class. This allows the group to retain and
maintain control of wealth, power, and prestige.
endometriosis A clinical condition often found among middle-class, col-
lege-educated career women in the United States in their twenties and
thirties consisting of patches of endometrial tissue that are found on ova-
ries, the external uterus, and other pelvic and abdominal organs and fallo-
pian tubes. It can cause fallopian tube blockage and scarring and interfere
with conception.
endometrium Interior lining of the uterus, innermost of three layers.
epidemic The rapid spread of a disease through a population.
epidemiology The study of the incidence, prevalence, and patterns of dis-
eases within and between populations.
epididymis Tubular structure on each testis in which sperm cells mature.
episiotomy A surgical incision in the vaginal opening made by the clinician
or obstetrician if it appears the perineum will tear in the process of birth.
erogenous (erotogenic) zone The parts of the body where touching or strok-
ing results in sexual excitement. The areas usually include, but are not
limited to, the breasts, lips, genital or anal regions, and buttocks.
458 Glossary
erogenous zone sensitivity Those parts of the body that produce sexual
arousal when stimulated.
erotocentricity The process whereby we allow our own culture’s sexual at-
titudes, values, and mores to bias our understanding of sexuality in other
cultures.
essentialist A person who believes that most behavior is based on genes,
hormones, and biochemical factors.
Essure Method Sterilization method in which a tiny tube shaped like a
spring is placed in each tube that causes the tubal lining to form scar
tissue and results in the obstruction of the fallopian tubes and prevents
passage of the egg.
estradiol An estrogen that effects the development and maintenance
of the female reproductive organs as well as all female secondary sex
characteristics.
estrogen Term given to a group of “female” sex hormones found in post-pu-
bertal males and females. It is largely responsible for primary and second-
ary sex characteristic development in girls.
estrus The reproductive cycle in female non-human mammals, which is ac-
companied by physiological, anatomical, and behavioral changes.
ethnocentrism The view that the cultural values and practices of one’s own
society are superior to all others.
ethnography The descriptive study of a culture; the research method of par-
ticipant observation in which the anthropologist becomes entrenched in
the lives of people in his/her research community.
ethos Approved style of life.
etic The interpretation of customs in a specific culture as seen by the out-
side observer. The use of descriptions and analyses in terms of conceptual
schemes and categories associated with industrialized scientific perspective.
etiology The origin of a disease or abnormal condition.
evolution The process of irreversible, qualitative change from one form or
another that occurs over time that allows species to adapt to their chang-
ing environments.
excision Refers to genital cutting during women’s rites of passage.
exogamy The marriage rule that requires its members to marry outside their
community, tribe, clan, or group.
explicit culture The knowledge about ourselves that can easily be commu-
nicated. Examples include genealogies and marriages.
expressive gender roles Refers to the emotional work of women in the family
and in relationships circa 1950s middle-class nuclear families. In 1995, the
sociologist Talcott Parsons contrasted women’s expressive roles with the in-
strumental roles of men characterized by work and the breadwinner role.
extended family A group of people consisting of parents, children, grand-
parents, aunts, uncles and other relatives. Relationships are consanguin-
eal (blood) and/or affinal (marriage).
extramarital sex Having sex with someone other than your spouse.
Glossary 459
exudate Vaginal lubrication.
Faith-Based Organizations (FBOs) Those organizations that are derived
from, supported by, and implemented by religious groups.
fallopian tubes Organ in the female that extends from the fundus of the
uterus for about five to seven inches to the ovaries. Hollow with hairlike
cilia along the inner walls, they are the size of a broom straw or strand of
spaghetti. Homologous and analogous to the vas deferens in males.
family of orientation The family into which a person is born or adopted.
family of procreation The family created through childbearing or adoption.
fellatee The recipient of oral stimulation of male genitals.
fellatio Stimulation of the male genitals with the mouth.
fellator Refers to the individual performing oral stimulation of male genitals.
female condom (FC1) Barrier method introduced in the 1990s; device made
of a seven-inch polyurethane bag held in place by two flexible rings one of
which is located outside vagina with the other against the cervix.
female condom (FC2) Barrier method; new version of the female condom
made of synthetic latex that is cheaper to produce.
female hormone patterning The cyclical release of estrogens and progester-
one triggered by fluctuations in the H-P-G axis.
female-to-male (FTM) transgender Person identified at birth as female but
who desires to live as a man or in an androgynous role. See transcender.
femininity A set of behavioral and affective characteristics associated with
the female gender role; can very often be stereotypic and culture-bound.
fertility awareness methods (FAMs) Methods of birth control where the
woman’s menstrual cycle is tracked to predict periods of safe and unsafe
days for coitus.
fertility The ability of a person to produce offspring.
fetal reduction Selectively aborting a fetus in a multiple pregnancy so that
the other fetuses have an increased chance of survival.
fetus The embryo after eight weeks of development until birth.
fictive kin People who are not related to you but stand in a kinship relation
to you.
follicle(s) Relative to human sexuality, the sacs in the ovaries that contain
the eggs.
follicular phase The first phase of the menstrual cycle during which egg
maturation and development occur.
follicular stimulating hormone (FSH) A hormone produced or secreted by
the anterior pituitary gland that stimulates sperm production in males and
follicle and ovum development in females.
foreskin Generally used to refer to the skin that covers the glans penis.
fraternal polyandry The marriage of brothers to the same woman with
whom they live patrilocally. All husbands take responsibility for the wom-
an’s children.
frenum/frenulum Thin tightly drawn fold of skin on the underside of the
penile glans; it is highly sensitive.
460 Glossary
fundus The rounded top part of the uterus.
gamete transplant A form of assisted reproductive technology (ART) in
which the sperm is transferred into the woman’s egg.
gamete The egg or sperm.
Gay, Lesbian, Bisexual and Transgender Pride Parades (Pride Pa-
rades) Annual parades held nationally and internationally that cele-
brate the diversity of genders and sexual orientations.
gay A biological male whose sexual and romantic attractions are to others
of his sex.
Gay-Related Immune-deficiency Disease (GRID) The erroneous label first
given to AIDS in the United States.
gender dysphoria Dissatisfaction with one’s gender.
gender identity The sense that one is a male, female, or some other gender.
gender role Often referred to as script or scripting of an individual. The
internalization and acting out of culturally defined male/female behavior,
affect, and attitudes.
gender schema Shared belief system about sex and gender.
gender selection A preference for males or females, sometimes selected be-
fore birth through chromosome filtration or abortion, or after birth as
with female infanticide.
gender A designation given to sexes in regard to biobehavioral and psycho-
social qualities.
genetic entities Refers to the unique genetic makeup of individuals.
genetic sex See chromosomal sex.
gestalt The concept used by Ruth Benedict by that the configuration of a
culture is presented as a whole formation which connotes more than its
component parts.
glans The acorn-shaped end of the penis that is covered by the foreskin and
which is highly sensitive to sexual stimulation; homologous to the glans clitoris.
GLBTQ acronym for gay, lesbian, bisexual, transgender, and queer
community.
globalization A process of economic, political, and social exchange and
change that has existed for millennia, but usually refers to the impact of
culture change between industrialized and nonindustrialized societies in
the twentieth and twenty-first centuries.
gonadotropic releasing hormone (GnRH) Hormone released by the hypo-
thalamus that stimulates the production of the pituitary hormone.
gonadotropins Generic term given for sex hormones. See sex hormones.
gonads Ovaries in female, testes in male. The gonads comprise one-third of
the H-P-G axis. They are the primary sources of estrogen and progester-
one production in females, and testosterone in males.
Grafenberg spot (G spot) The Grafenberg or G spot is located approxi-
mately one or two inches inside the opening of the vagina on the anterior
wall about halfway between the outer labia and the cervix. It is named
Glossary 461
after Dr. Ernst Grafenberg, (1950) who first located and described the
dime-sized spot in a 1950 report.
grasping hand A hand with a thumb that is opposable to other digits, en-
hancing the ability to grasp (grab) objects.
group marriage As practiced by the Oneida Utopian Christians in commu-
nal living, the practice where all members regard one another as spouses.
G-spot model The Grafenberg spot is an area of sensitive tissues located one
or two inches inside and on the anterior wall of the vagina. It is debated
whether it is involved in orgasm.
gynecomastia Breast enlargement in the male.
heteronormative The idea that everyone is heterosexual.
heterosexual Sexual and romantic attraction to the other sex.
Highly Active Antiretroviral Therapy (HAART) A combination of drugs
called anti-retrovirals given to people with HIV to reduce their viral load,
increase their T-cells and prevent them from contracting an Opportunis-
tic Infection.
hijras Indian group recognized as third gender and usually born as men and
become transformed through ritualized surgical emasculation in which
genitals are removed.
HIV infection The state of being HIV positive, determined through an HIV
antibody test.
HIV testing A blood or buccal membrane test that can be a preventive tool
or basis of an initial diagnosis of HIV infection and AIDS.
HIV See human immunodeficiency virus.
HIV-1 Retrovirus associated with HIV in this country.
HIV-2 A variety of HIV-1 found in West Africa.
holism An all-embracing outlook that “refers to the study of the whole of the
human condition; past, present, and future; biology, society, language and
culture” (Kottak, 2002 4).
holistic approach The view that all parts of a culture are interrelated; leads
to the study of all aspects of a culture and how they are interrelated.
hominid Humans and their direct ancestors
homologous/homologues Structures that develop from the same embryolog-
ical tissue.
homophobia Strongly held negative attitudes and irrational fears of homosexuals.
homosexual The sexual and romantic attraction to people of one’s own sex.
hormonal method Birth control method using estrogen and progesterone
and other hormones.
hormone replacement therapy (HRT) The use of supplemental hormones
during and after menopause; also referred to as menopausal hormone
treatment (MHT).
hormone therapy (HT) Generally referring to drugs given to peri- and
post-menopausal women to treat the symptoms of menopause such as hot
flashes and vaginal drying.
462 Glossary
hormones Substances released by the endocrine (ductless) glands that affect
anatomical development and functioning.
horticulture Describing a farming community; a form of cultivation also re-
ferred to as hoe or digging stick agriculture in which wide areas of land are
farmed until they are depleted and there is an absence of the use of irriga-
tion, crop rotation, and fertilizer. Often associated with endemic warfare
and impacted habitats.
H-P-G Axis Composed of the hypothalamus, the pituitary, and the gonads.
This is the hormonal basis of sex and reproduction. This axis forms a net-
work for understanding puberty, sexuality, and reproduction.
human chorionic gonadotropin (HCG) Produced by the chorion and often
referred to as the pregnancy hormone; HPG is detected by standard at-
home pregnancy and clinical pregnancy tests.
Human Immunodeficiency Virus (HIV) A retrovirus that leads to a deple-
tion of immune cells and eventually a diagnosis of AIDS.
Human Relations Area Files (HRAF Files) Classification scheme devel-
oped by G. P. Murdock that serves as the basis for statistical comparison
for anthropologists.
human sexuality The evolutionary, biochemical, anatomical, and socio-cul-
tural dimensions from birth to death that relate to sexual behavior, be-
liefs, values, and symbols.
H-Y antigen Testosterone; a substance found in the in utero sexual differen-
tiation of chromosomal males.
hymen Membranous tissue that can cover part of the vaginal opening.
hypothalamus/hypothalamic A ductless gland located in the brain that
contains neurosecretions used in controlling certain metabolic actions
like the maintenance of the body’s water balance, sugar and fat metabo-
lism, the regulation of body temperature, and the secretion of FSH, LH,
and LTH.
ideal culture The normative expectation or behavior of individuals in a
given culture.
illness The socio-psychological and economic aspects of being sick that af-
fect the individual, the family, and possibly the community.
immediate family Term used in the United States to designate those with
close family relationships (husband, wife, mother, father, children, grand-
parents, siblings).
impacted habitats Econiches characterized by natural boundaries that set
limits to a group’s expansion. These boundaries can include volcanoes,
mountains, or impenetrable forests.
Implanon A 1.5–inch rod that is injected under the skin of the upper arm
of a woman and offers protection against pregnancy for up to three years
through delivery of progestin that prevents ovulation.
in vitro fertilization (IVF) A technological process whereby the union of
the sperm and egg occurs outside the mother’s body.
Glossary 463
incest taboo The universal prohibition against marrying or mating within
the primary family. The prohibition of sexual relations exists between
mother and son, father and daughter, and brother and sister.
incidence The number of new occurrences of a disease in a population.
incorporation In rites of passage, the phase in which the initiates are inte-
grated back into their society/social group in their new status.
independent household Also known as neolocality. A newly married couple
moves away from both set of parents to make their home in a different area.
indigenous cultural integrity Refers to the survival of indigenous core cul-
tural features, patterns, beliefs, values, and systems.
indigenous sexual behaviors Sexual behaviors specific to a particular group.
induction method Abortion option used in late-term pregnancies and used
only when a severe medical problem for the mother or the fetus exists.
Medication is injected into the amniotic sac and vagina to cause contrac-
tions and the expulsion of the non-living embryonic tissues.
infant dependency The period of time when the young are dependent upon
adult caregivers for survival.
infanticide Method used to control birth found in a variety of forms around
the globe and involves infant death.
infertility A couple’s inability to conceive and bear a child after one year of
trying.
infibulation Surgical procedure, performed in some cultures, that seals the
opening of the vagina and removes the clitoris.
initiation ceremonies Public recognition that facilitates the movement from
childhood to adulthood. These may be stressful, often include rigorous
tests, hazing, isolation from younger friends, and painful ordeals.
injection drug use (IDU) Intravenous or subcutaneous use of drugs that can
be recreational and often are illegal.
inseminate To deposit ejaculate (semen) in the body.
inseminatee Among the Sambia, the inseminatee is a boy who is the fellator
of other males as part of a rite of passage into manhood in which he must
build up his supplies of semen through ingesting it.
inseminator See fellatee.
instrumental gender role Boys’ traditional industrialized socialization into
roles associated with acting or achieving, circa 1950s middle class.
interactionist approach The interaction of both biological and environmen-
tal variables and the nature of this interaction in the study of human
sexuality; also referred to as integrationist approach.
interfemoral intercourse Position where the penis is placed between the
partner’s thighs.
intermediate societies Joint household domesticated food economies like
pastoralists and horticulturalists.
intersex Individual possessing sexual characteristics of both male and fe-
male. Also referred to clinically as hermaphrodite.
464 Glossary
interstitial cell stimulating hormone (ICSH) Pituitary hormone that stim-
ulates the testes to secrete testosterone. Also known as LH in females and
males.
interstitial cells Cells in the testes that are a major source of testosterone.
interventionist and non-interventionist Describes the continuum that re-
fers to the degree of active involvement of others, use of drugs and other
technology in a woman’s labor and birth.
intimacy Late twentieth-century middle-class term for bonding. The deep,
intense, psychological, social, and emotional bonds between individuals
that may or may not include sexual behavior.
intrauterine device (IUD) Birth control method; a small metal or plastic
device placed in the uterus.
introitus The outer opening of the vagina.
involution The return of the uterus after childbirth to its prepregnant size
and shape.
jerungda The vital life force in men that the Sambia believe is found in ejac-
ulate. Jerungda is potentially exhaustible, and therefore ejaculate is both
an essential body fluid and believed to exist in finite quantities.
joint household residence The practice of living with or near one of the
couple’s parents.
kin groups Descent that is determined by social position and cultural mean-
ing. These links are formed through marriages and reproduction.
Kinsey Report One of the earliest formal studies in United States of sexual
behavior which has generated controversy.
kinship A method for ordering human social relations and creating groups
and boundaries.
Klinefelter’s Syndrome A genetic condition represented chromosomally
by an XXY combination and occurring in about 1/500 to 1/1000 live
births.
labia majora Major or large lips of tissue on either side of the vaginal opening.
labia minora Smaller lips of tissue on either side of the vagina.
labor The time during childbirth when the woman’s os dilates and the baby
passes through the cervix into the vagina.
lactation The production of milk from the mammary glands of mammals.
laparoscopy Surgical procedure that involves an incision in the abdomen
where organs are viewed through a lighted tube or laparoscope.
Late Luteal Phase Disorder (LLPD) The medical term given to what is
popularly referred to as Premenstrual Syndrome (PMS), also referred to as
premenstrual dysphoric disorder (PMDD).
latency stage A Freudian psychosexual stage from six years of age to puberty
when children lose interest in sex.
Lea’s Shield Barrier method approved by the FDA; a dome-shaped rubber
disk with a valve and loop that is held in place by the vaginal wall.
lesbian A biological female whose sexual and romantic attractions are to
others of her own sex.
Glossary 465
levirate A tradition practiced in some cultures where a man is required to
marry a deceased brother’s wife.
Leydig cells Cells located between the seminiferous tubules that are the ma-
jor source of androgen in males.
liaisons Unstable relationships based solely on sex.
liberated gender role It refers to a state of being culture-free of negatively
perceived gender role expectations; that is, traditional roles, regardless of
one’s gender. It is individually oriented and defined, another phenomenon
characteristic of the United States.
libidinous functioning General reference to one’s sexual interest in relation
to sexual expression.
libido A desire for sex. Freud considered it natural, present at birth, and fo-
cused in various areas of the body.
life cycle The course of life from birth through death.
liminality In rites of passage, these are the threshold rites that prepare
an individual “for his or her reunion with society” (Van Gennep, 1960
[1909] 21, 46, 67). Also referred to as the transition phase.
luteal phase The third phase of the menstrual cycle. Conception occurs
during this phase.
lutenizing hormone (LH) Hormone secreted by the pituitary gland that
precipitates ovulation in females and maintains the Leydig cells in
males.
luteotropic hormone (LTH) Hormone that helps maintain uterine tone,
promotes progesterone production, directly involved in the lactation pro-
cess and may be involved in testosterone production.
machine suction Abortion method used between the six to twelve weeks
after conception to remove endometrial tissue from the uterus.
mahu Tahitian gender variant status for men.
maidenhood Time frame in a girl’s life between menarche and full
adulthood.
Maithuna Sexual union in Tantric doctrine; a way to approximate merging
with the sacred.
male climacteric Sometimes termed “male menopause.” At about the same
age that women experience menopause, men have decreased testosterone
production and, in industrialized countries, often begin to question the
direction their lives are headed.
male condom Made of latex rubber, lamb intestine, polyurethane, or synthetic
elastomers, this device covers the penis and contains ejaculated sperm.
male menopause See male climacteric.
mandatory contact tracing A process where sexual and needle-sharing part-
ners of HIV-positive people are contacted through one of several interven-
tions. Notification can be made by the infected people to their partners
(good faith), by the Department of Health to the partners of HIV-positive
individuals, or by having the HIV-positive individuals bring their partners
to a post-test counseling session.
466 Glossary
mandatory name reporting Procedure used in the United States since 2000.
If a person tests positive in a confidential HIV test, their names, location,
ethnicity, age, gender, and mode of transmission are reported to their state
agency of health and the CDC.
manual vacuum aspiration method (MVA) Abortion method whereby tis-
sues from the uterus are gently suctioned through a handheld device. This
method is used as early as three to seven weeks after a missed menstrual
period.
marital ties Those individuals who are related by marriage. For example,
“in-laws” in US culture.
marriage A public and social ceremony between two or more people that
creates relationships, sexual and economic rights, and obligations within
the union. It also provides a means for incorporating offspring into the
group.
masculinity A pattern of learned, verbal/non-verbal signs, symbols, and be-
haviors that reinforce the socially defined concepts of male gender; may
reinforce stereotypes and be culture-bound.
master gland Also known as the pituitary. An organ in the brain which, as
one of its functions, releases hormones necessary for sperm formation and
egg development.
masturbation Sexual self-stimulation, generally of one’s genitals.
mateship A public and social ceremony between two or more people that
creates relationships, sexual and economic rights, and obligations within
the union. It also provides a means for incorporating offspring into the
group.
matrescence The sociological process of becoming a mother.
matricentered, matricentricity Weighted toward the female, valuing a fe-
male perspective, structure, values, and belief system.
matrilineal descent The practice of tracing descent through the female line.
matrilocal residence The practice in which a married couple moves to live
near or with the bride’s family.
matrilocality This refers to living arrangements where a couple resides in the
community of the wife’s mother. Also referred to as matrilocal residence.
medicalization The classification of health, illness, and normalcy into indus-
trial medical categories that emphasize dysfunctions and disorders.
medication abortion Hormonal method of abortion.
menarche rituals Rites of passage related to females’ first menstruation.
menarche Onset of menstruation.
menopause The period of cessation of menstruation occurring usually be-
tween the ages of forty-five and fifty-five.
menses Menstrual blood composed of blood, tissue, and mucous.
menstrual cramps Uterine contractions caused by prostaglandins.
menstrual cycle Primary sex characteristic in the female that involves mat-
uration and release of an egg from the ovary, preparation of the endo-
metrium for either implantation of a fertilized egg or sloughing of the
Glossary 467
endometrium if fertilization has not occurred, and discharge of the men-
ses if there is no implantation.
menstrual synchrony Eventual synchronization of menstrual cycles among
women who live near one another and are in close contact.
menstruation The fourth phase of menstrual cycle when the endometrium
is shed as menses; generally lasts four to seven days.
midwives Women trained in administering pre- and post-natal care and at-
tending births.
mifepristone Hormonal method of abortion which is also known as RU
486. This method induces menstruation by interfering with production
of progesterone.
migration The movement of people into a region where they seek perma-
nent residence.
mini-pill Hormonal method for females that contains only progesterone,
which inhibits the development of the uterine lining.
misoprostol Hormonal method of abortion used with mifepristone that
causes the cervix to soften and the uterus to contract.
mittelschmerz The release of the egg from the ovary that some women ex-
perience as a cramping sensation.
modes of transmission Transmission of HIV through infected blood, semen
or vaginal fluids, or from mother-to-child during pregnancy or birth and
through breastfeeding.
moiety system Society is divided into two large social groups.
monogamy Marriage to only one partner.
mons, mons pubis, mons veneris Cushion of fatty tissue located over the
female’s pubic bone.
mortality The incidence of death rates.
Mother-To-Child-Transmission (MTCT) The mechanisms by which HIV
can be passed from mother to her fetus, infant, or child.
Müllerian ducts Found in both embryonic males and females. Prenatal
structures that develop into the broad ligament uterus, fallopian tubes,
and upper third of the vagina.
Müllerian Inhibiting Substance (MIS) A hormone released by embryonic
males to close their Mullerian ducts.
mutual masturbation Stimulations of one’s partner’s genitals, usually manually.
myometrium The middle layer of the uterus; consists of smooth muscle,
thereby aiding the pushing of the newborn through the cervix.
nadle Third gender position ascribed on the basis of ambiguous genitals
among the Navajo.
negative feedback cycle A term used to refer to the release of hormones
during the menstrual cycle where a decrease in one hormone triggers the
release of another one.
negative feedback loop A regulatory system that coordinates the production
of gonadal hormones through the complex interaction of the gonads, the
hypothalamus, and the pituitary gland.
468 Glossary
neolocality The practice where the young married couple lives apart from
their parents in their own home, usually in a different area.
neonatal Referring to the care of newborns.
neonate Newborn.
“noble savage” Notion derived from early anthropological reports of “exotic
natives” communing with nature in its unspoiled and pristine state con-
tinues in popular culture.
non-government organizations (NGOs) Organizations that are not spon-
sored or under the aegis of the government.
non-interventionist When applying to childbirth, the practice of using min-
imal interventions during the labor and birth of the child.
non-traditional gender role Concept developed in the 1960s to refer to peo-
ple who challenged the accepted cultural norms and structures about how
men and women were to behave.
non-unilineal descent (bilateral, double descent) The practice of tracing
one’s descent through both parents with each of these in control of differ-
Norplant Hormonal birth control method placed under the skin of the arm
that releases progestin and provides protection against pregnancy for five
years unavailable in the United States.
nuclear family A grouping of individuals of a household made up of a mar-
ried couple and their children.
Oedipal phase (phallic stage) The Freudian psychosexual stage that occurs be-
tween the ages of three and five, characterized by love, hate, envy, and guilt.
oedipal phase. phenotypic sex The physical expression of either the XX or
XY genotype including structures such as ovaries, labia majora and minor,
or the penis, testes, and scrotum.
Oedipus (Oedipal) complex Named for the tragic mythical hero, Oedipus,
who unknowingly fell in love with and married his mother. Oedipus
blinded himself when he realized what he had done. The Freudian term is
used to refer to a young boy who covets his mother while competing with
his father.
olfaction Sense of smell.
olfactory cues Sexual scent signals.
olfactory kiss See smell kiss.
omnivorous A diet composed of both meats and vegetables.
ontogenetic level Also known as the developmental level of the three cate-
gories of levels of explanation; seeks causes in external and internal expe-
riences in the individual’s lifetime.
oophrectomy Surgical removal of the ovary or ovaries.
open biogram An extremely flexible genetic program that is shaped by learn-
ing experience.
opportunistic infections (OIs) Those bacteria, viruses, fungi, and protozoa
generally found in someone with a compromised immune system. One of
the defining criteria for an AIDS diagnosis.
Glossary 469
Opt-In Testing HIV testing that occurs by someone specifically agreeing to
have the test.
Opt-Out Testing HIV testing that occurs by someone specifically declining
to have the test.
oral combined contraceptive Pill that contains synthetic estrogen and levo-
norgestrel; taken within seventy-two hours of intercourse, it is 75 percent
effective in preventing pregnancy.
oral contraceptive pill (OCP) Hormonal method that combines estrogen
and progesterone that tricks the body into thinking it is pregnant and
prevents the egg’s release.
oral stage The Freudian psychosexual stage of development that occurs from
birth to one year of age in which an infant’s interest centers on the mouth
as a source of pleasure.
orchidectomy The surgical removal of the testes. See castration.
orgasm Sexual climax. The intensely pleasurable feeling that comes at the
end of stimulation to the genital organs (clitoris, vagina, penis).
orgasmic platform Reached during the stage when the vaginal opening is
reduced in size because of engorgement of the surrounding erectia tissue.
os The opening of the cervix.
osteoporosis A degenerative bone disease common in older women and men.
out Term used for male and female homosexual people who are open about
their orientation.
ovary/ovaries The organ in the female responsible for egg maturation, the
release of estrogen and progesterone, and some testosterone.
overdetermination of women’s selfhood Rules of conduct that are more
restrictive for women than for men and emphasize control over wom-
en’s bodies that are usually associated with patricentric and patriarchal
societies.
ovulation The release of the egg from the ovary.
ovum/ova The egg(s).
oxytocin A labor-stimulating hormone.
paleoanthropologists Scholars of human evolution.
pandemic A disease that is found globally.
Papanicolaou smear (Pap smear) Part of a gynecological exam where cells
are gently scraped from the cervix and analyzed to detect cervical nor-
malcy and abnormalities including cancer.
parallel cousins Children of one’s mother’s sister or father’s brother.
parametrium Outer covering of the uterus.
paraurethral glands Glands on either side of the Grafenberg spot that se-
crete a fluid into the urethra upon sexual stimulation.
participant-observation Research method in which an anthropologist be-
comes entrenched in the lives of the people in their research community.
passage ceremony See rite(s) of passage.
patch, the Hormonal contraceptive containing estrogen and progestin
which is applied once a week for three weeks to the upper body, lower
470 Glossary
abdomen, or buttocks. It is removed during the fourth week for menstru-
ation to occur.
paternity certainty Firm knowledge of the father of an offspring.
paternity Blood relationship traced to the male or father.
patrescence A status change for the male after the birth of his child.
patriarchy Reference to a society in which males have privileged access to
prestige, power, and resources.
patricentered, patricentricity Weighted toward the male, valuing a male
perspective, structure, values, and belief system.
patrilineal descent Tracing kin through the male line.
patrilocality (residence) Post-marital residence where the couple lives near
or with the groom’s family.
penile-vaginal intercourse (p-v sex) Insertion and incorporation of the pe-
nis in the vagina; colloquially, what many people in the United States
refer to and think of as “sex.”
penis A primary male sexual and reproductive organ.
People Living with HIV/AIDS (PLWH/A) Those individuals who are HIV
infected or who have AIDS.
PEPFAR Implemented under George W. Bush’s Presidency, the President’s
Emergency Plan for AIDS Relief. This plan provides resources for fifteen
countries seriously impacted by HIV, but the plan mandates 30 percent of
the resources earmarked for prevention goes to abstinence-only programs
and condoms are only for prostitutes, gay men, injection drug users, and
those who “can’t be abstinent.”
performance Socially acquired lifeways and patterned interactions; the
things humans do and make.
perimenopause Climacteric period that begins five years prior to last men-
strual cycle and covers a ten-year period.
perineum Sensitive area of skin between the scrotum or vagina and the anus.
phallic stage The Freudian model of psychosexual development occurring be-
tween the ages of three and five years. Often this is characterized by love,
hate, envy, and guilt and fascination with one’s genitals. See oedipal phase.
pheromones Chemical signals; hormones produced by the body that either
attract or repel the other sex.
phratry A large grouping of people of unilineal descent composed of several
clans.
PhRMA An international prescription drug cartel that sets prices and regu-
lates access to and the distribution of drugs cross-culturally.
physiology The function of an organ or body structure.
pituitary Also known as the “Master” gland, an organ in the brain which,
as one of its functions, releases hormones necessary for sperm formation
and egg development.
placenta That structure in female mammals, primates, and humans that at-
taches to the uterine wall during pregnancy, providing nutrients to the
fetus and filtering fetal wastes.
Glossary 471
Plan B A hormonal option for emergency contraception; a progestin-only
pill taken in two doses twelve hours apart or two doses taken at the same
time.
polyandrous marriages Unions that help maintain family landholding units
against possible subdivision through individual inheritance and partition
of lands.
polyandry The practice where one woman has several husbands at the same
time. A form of polygamy practiced in Tibet, Nepal, India, Sri Lanka, and
by the Marquesans of the Pacific.
polygamy Marriage to multiple partners (spouses) at the same time.
polygyny/polygynous The practice where one man has several wives at the
same time.
population control Any means a group uses throughout the life cycle to con-
trol its size.
post-exposure prophylaxis (PEP) ARVs given to someone immediately af-
ter exposure to HIV in order to reduce the chances of infection.
postpartum depression A culture-specific, bio-cultural phenomenon found
more often in women in the United States than elsewhere where they
become depressed after giving birth.
postpartum The period after birth.
pre-ejaculatory fluid A clear, slippery fluid released from the Cowper’s gland
into the urethra before ejaculation that neutralizes the acidity of the urethra.
pregnancy The time from implantation of the fertilized egg into the uterine
wall until after the placenta has been born.
premarital sex Sex before marriage.
premenstrual syndrome (PMS) A collection of symptoms that some women
in industrialized societies experience the week before menstruation that
can include food cravings, mood swings, and bloating. The existence and
nature of PMS is controversial.
prepuce In the female, the upper part of the labia minora that covers the
clitoral shaft, known as the “clitoral hood.” In males, the foreskin, a loose
tissue covering the glans.
prevalence How widespread a disease is in a population.
primary orgasmic dysfunction Clinical term that refers to women who have
never experienced an orgasm.
primary sex characteristics Those structures in both the male and female
related to the reproductive cycle and directly involved in sexual and re-
production function.
primates An order in the phylogenetic tree characterized by large-brained,
highly social creatures of which prosimians, monkeys, apes, and humans
are members.
proceptivity Actively seeking a mating opportunity.
progesterone A “female” sex hormone found in post-pubertal females
and males and responsible for the development of certain primary sex
characteristics.
472 Glossary
prolactin (PRL) A hormone found in the pituitary gland that is involved
with breast development and the production of milk during lactation
(nursing or breastfeeding).
promiscuity A highly value-laden term referring to the number of sex part-
ners a person has; often applied to females.
pronatalism/pronatalist The belief or practice of regarding the fetus as pri-
mary and/or more important than its mother.
prostate A walnut-sized organ surrounding the male urethra that releases
semen.
prostatitis A localized or systemic infection or irritation of the prostate.
prostaglandins Hormones produced in the uterus that contract the uterus.
prostitution A specific form of sex work that involves the exchange of sex
(left undefined) for money, goods, or services (goods and services are
undefined).
proximate level One of the levels of explanation that seeks causes in the
immediate external and internal environment.
psychoanalysis Freudian technique used in treating personal and psycho-
logical disorders in which people explore their pasts to gain insights into
their current behaviors and feelings.
puberty The stage of life when a person develops secondary sexual charac-
teristics and begins spermatogenesis or the menstrual cycle.
pubic bone (pubis) The pelvic bone that lies beneath the mons.
pubic hair A secondary sex characteristic of hair distribution in males and
females that covers the genitalia.
pubococcygeus muscles Muscles encircling the vagina and the crura.
quickening The time when a woman first feels the fetal movement.
ramage Ambilineal descent in which groups are formed by household and
common ancestors; may be stratified internally.
real behavior/culture This term is usually used to contrast with the term
“ideal” behavior/culture. Ideal culture is what is expected in contrast to
what people actually do, which is termed “real” behavior/culture. This may
be contrasted with “perceived behavior,” what others think they are doing.
receptivity Willingness to engage in sexual activity with a partner.
recreational ideology Industrialized men are socialized in a recreational
model of sexuality to experience sex as conquest with the goal orientation
of orgasm.
relational ideology Industrialized women are socialized in a relational model
to experience sex as intimacy and as a process of achieving closeness.
relatives People linked to individuals through the kin of both sexes.
reliance on learning The principle that most behaviors are learned rather
than genetically determined for humans.
reproduce To produce offspring.
reproductive cycle That component of sexuality involved in the structures
and behaviors that can result in offspring.
Glossary 473
reproductive functions Those functions that result in offspring and include
spermatogenesis, ejaculation, the menstrual cycle, pregnancy, and birth.
reproductive structures Those structures directly involved in reproduction.
reproductive success The ability of a species to produce enough viable
young who live to reproductive age to continue the species.
resolution Final phase of human sexual response.
rete testes The rudimentary structure that develops from the Wolffian ducts.
retrovirus A virus whose genes are in the form of RNA.
rhythm method A natural birth control method entailing abstinence during
the ovulatory phase of the menstrual cycle.
rite(s) of passage The symbolic or ceremonial observance that occurs when
an individual moves from one stage in the life cycle to the next. This in-
cludes three stages separation, transition (liminality), and incorporation.
ritual marriage A relationship where a woman marries a man from a linked
lineage. Associated with specific polyandrous forms of marriage.
ritual totemic meal According to Freud, the occasional ritual eating of the
totemic animal that is usually proscribed is evidence of the commemora-
tion of the original primal scene in which the sons killed their father and
is the origin of the incest taboo.
root The part of the penis and clitoris that is attached to the body.
safe sex Those behaviors that will not transmit HIV or other STIs.
safer sex Those behaviors that reduce the risk of transmitting HIV or other
STIs.
script/scripting Gender role; the internalization and acting out of culturally
defined male/female behavior, affect, and attitudes.
scrotal sac/scrotum The multilayered pouch of loose skin located between
the penis and contains the testicles, epididymis, and spermatic cords.
secondary orgasmic dysfunction Clinical term that refers to women who
have once been orgasmic but who are no longer.
secondary sex characteristics Those structures in both the male and fe-
male that are often directly involved in sexuality, indirectly involved in
reproductive functioning, and are frequently used as cultural markers of
physiological sexual maturity and gender signals.
semen The fluid produced in the seminal vesicles and prostate that trans-
ports and nourishes the sperm.
seminal vesicles Two structures that provide most of the semen.
seminiferous tubules Tightly coiled tubes in the testes where the sperm develop.
separation In rites of passage, the phase in which an individual is removed
from his or her previous world or place in society.
sero-discordant couples Couples in which one person is HIV-positive and
one person is HIV-negative.
sex drive Sometimes referred to as the libido, the interest in behaving sex-
ually that is, in part, a function of testosterone, but largely a function of
socio-cultural factors.
474 Glossary
sex hormones Those hormones, specifically testosterone and its derivatives,
estrogen in its varied forms, and progesterone, that are responsible for the
development and expression of male and female primary and secondary
sex characteristics, respectively.
sex signal Erotic symbol.
sex tourism An international industry where people travel to specific coun-
tries in order to hire and engage in a variety of sexual activities.
sex work An inclusive term referring to formal exchanges of money, goods,
or services for various kinds of sexual behavior.
sex As in male, female, intersex, or other, typically refers to biological attri-
butes including chromosomes, external genitals, gonads, internal repro-
ductive structures, hormonal states, and secondary sexual characteristics,
among others.
sex-gender system The sex-gender system refers to the relationship of the
biological, the social, and the cultural system as mediating the expression
of gender roles and sexuality. Sexuality and gender may be analytically
distinct but intersect in the lives of humans in particular ways depending
on cultural context.
sexology The study of sexual attitudes and behaviors by scientific means.
sexual addictions Desire disorders of a “hypersexual” response, known pop-
ularly as sexual addiction. This “problem” is not included in the DSM,
although it is included in the World Health Organization’s International
Classification of Diseases (ICD 10, 1992; King, 2005).
sexual behaviors The type of behavior that one expresses; distinct entity
from sexual orientation.
sexual cue(s) Visual clues of stimulation.
sexual culture Defined by Gilbert Herdt as the “intrinsic or internal mean-
ing, as well as extrinsic or environmental sources of sexual behavior”
(Herdt, 1999 100).
sexual cycles Those behaviors and anatomical structures that primarily deal
with sexual arousal and release.
sexual desire disorders A broad category of sexual problems related to hav-
ing an interest in behaving sexually.
sexual differentiation The process by which male and female sexual and
reproductive anatomy develops in utero.
sexual double standard Sexual norms commonly found in bilateral and
patrilineal descent societies where men and women’s sexual behaviors are
perceived and responded to differently.
sexual functions The anatomical (e.g., clitoris), psycho-social, and emo-
tional components of sexual desire, arousal, and orgasm.
sexual orientation The sex to which one is sexually attracted.
sexual partnership Two people who have sexual relations with each other.
sexual prohibitions These are cultural rules defining appropriate and inap-
propriate categories of marriage and sexual partners.
Glossary 475
Sexual Revolution A part of the 1960s when a tremendous amount of time,
energy, and attention was directed toward defining and elaborating the
concepts of gender role, gender identity, and sexuality.
sexual risk continuum The continuum of sexual behaviors from riskiest to
least risky regarding sexual susceptibility for contracting HIV.
sexual scent signals Pheromones.
sexual structures Structures primarily involved in sexual arousal and re-
lease such as the clitoris.
sexual subjectivity How we experience and express sexuality including indi-
vidual activities like personalities, histories, and sense of self.
sexually transmitted infections (STIs)/sexually transmitted diseases
(STDs) STIs are those bacteria, viruses, fungi, creatures such as pubic
lice, and protozoa that are transmitted sexually. STDs are the physical
manifestations of being infected with an STI.
shaft The long part of the penis ending in the glans.
show The mucous “plug” or substance that covers the os during pregnancy
that is expelled as blood and mucous during the early stages of labor.
situational orgasmic dysfunction Clinical term that refers to women’s prob-
lems of achieving orgasm in certain contexts but not others.
Skene’s Glands Also known as the paraurethral glands. Glands on either
side of the Grafenberg spot (G-spot) that secrete a fluid into the urethra
upon sexual stimulation.
smegma White, lubricating, cheese-like substance secreted underneath the
foreskin of the penis and prepuce of the clitoris.
smell kiss Nose is placed on the partner’s face as one inhales.
social construction/constructionism Theory of how societies produce and
create sexual meanings, behaviors, and subjectivities.
social organization Relationship seen through kinship and marriage
and also through institutional structures such as religion and political
organizations.
social structures Used in reference to social systems and the impact of insti-
tutions and socioeconomic status factors on sexual behavior.
social system A set of patterned interactions incorporating various institu-
tions, including the sex and gender systems.
sororal polygyny A situation where men marry their wives’ sisters in the
belief that this will contribute to household harmony and productivity.
sororate The practice where a man marries his dead wife’s sister. In some
cultures this is required after the death of a spouse.
species Defined as a “population or group of populations that is capable of
interbreeding but that is reproductively isolated from other such popula-
tions” (Haviland, 1989 66).
spectatoring A behavior in which an individual or couple monitor their
sexual response, thereby detracting from the pleasure the individual or
couple experiences.
476 Glossary
sperm banks Repositories of donated ejaculate that have been medically
and genetically screened and HIV tested, which are used for artificial
insemination-donor.
sperm count, motility, and form The criteria used to determine a man’s
fertility.
sperm count Any sperm count at or below 20 million per ejaculate renders
a man “subfertile.”
sperm form The head, midsection, and tail of sperm. All sections must be
present for impregnation to occur.
sperm motility The mobility or rapidity of sperm movement.
sperm Male sex gamete produced in the testes.
spermatic cord Male organ located on the side of each testicle and extend-
ing to the pubis that contains several structures such as the cremasteric
muscle, vas deferens, blood vessels, and nerves.
spermatic economy A widely held nineteenth-century western belief that
ejaculate exists in finite quantities in a man’s life.
spermatogenesis The formation of sperm.
sponge A barrier method used with a spermicide; can be inserted up to
twenty-four hours before penile-vaginal intercourse.
stereoscopic vision The development of three-dimensional vision that oc-
curred in primate and hominid evolution with the location of the eyes on
the front of the face. Represents an adaptation related to primate arboreal
and subsequent terrestrial environments.
steroids A class of hormones that includes androgens.
straight Argot for heterosexual people.
subfertility See adolescent sterility.
subincision Incision on the underside of the penis.
superincision Incision on the upper side of the penis.
“Supermale Syndrome” Also known as the XYY syndrome, the genetic
chromosomal makeup of XYY and occurs in about 1/1,000 live births.
survival of the fit Those individuals who are better adapted to their envi-
ronments will be more likely to reproduce surviving offspring than those
who are not. Those individuals who reproduce themselves are more likely
to pass on the traits they possess than those who are not so well adapted
to their environments.
survival sex Exchange of sexual behaviors for money, food, shelter, and/or
protection for a woman and possibly her family.
sweatshops Factories and businesses in industrialized and nonindustrialized
countries that pay very low wages, have unsafe working conditions, long
work days without breaks, and offer no benefits such as sick leave, vaca-
tions, or health insurance.
syncretism The blending and mixing of indigenous cultural elements with
those introduced by other societies; the “interplay of local, regional, na-
tional and international cultural forces” (Kottak, 2002 504).
Glossary 477
tacit culture Shared rules that an individual learns unconsciously from
those around them regarding behavior.
Tantra A sect of Hinduism practiced in India.
tenting orgasm An orgasm that occurs with clitoral stimulation after which
the inner portion of the vagina balloons as a result of the lifting up of the
uterus.
terminal disease A disease that is fatal.
testes Primary source of testosterone and other androgens in the male, as
well as where sperm are produced.
testicles See testes.
testicular self-exam (TSE) A self-examination men can do to detect
changes in their scrotal sac, testicles, and spermatic cord.
testosterone Considered the “male sex hormone”; found in post-pubertal
males and females. Responsible for the libido or innate sex drive in people
and primary and secondary sex characteristic development in the male.
theoretical effectiveness rate The effectiveness rate of a given method of
birth control based on laboratory conditions and correct and consistent
practices.
third sex A term applied to people identifying as something other than a
male or female. There may be more than three referred to as supernumer-
ary genders or gender variance.
threshold level The amount of testosterone required to maintain the libido
in men and women.
tonic Ongoing releasing patterns.
tonicity Refers to the pattern of male gonadotropic hormone release.
totem animal Freudian concept in which the symbol that represents the fa-
ther is ritually eaten in commemoration.
traditional gender role Conforming to mid-twentieth century US structures
and norms regarding appropriate behavior for males and females.
trafficking The movement of individuals and groups within and across
borders for economic purposes that can include prostitution, slave labor,
sweatshop conditions in businesses or factories, or indentured labor in
residences of wealthy people. Trafficking is generally illegal.
transgender A recent addition to industrialized gender-variant social iden-
tities. A community term that regards gender-variant identities as a con-
tinuum that includes the traditional transsexual and cross-dresser and
identities that lie in between and beyond.
transition See liminality.
transsexual An individual who has the phenotype of one gender, but the
gender identity of another. See transgender.
transurethral resection of the prostate (TURP) A surgical procedure to
reduce benign (or non-cancerous) enlargement of the prostate.
transvestic fetishism Classified by DSM-IV-TR as a paraphilia (problematic
sexual desire or behavior).
478 Glossary
transvestite A clinical term for an individual, usually male, who dresses in
clothing of the other sex. Cross-dresser is the preferred term among the
trans community.
tubal ligation Sterilization method where surgical procedure cuts, cauterizes,
bands or ties the fallopian tubes.
tubal patency Having unblocked fallopian tubes.
Turner’s Syndrome Genetic anomaly represented by an X or XO combina-
tion and occurring in 1/4000 live births.
two spirit Acceptable term for Native American gender-variant individuals.
Type I Excision. See clitoridectomy.
Type II Excision of clitoral hood, clitoredectomy and/or partial/total re-
moval of labia minora.
Type III See infibulation. Surgical removal of external genitalis with su-
turing of vagina opening.
Type IV Practice that includes various modifications of the female genital
area, but not removal of, tissues.
ultimate level The final level of the three levels of explanation; the evolu-
tionary explanation seen as being the result of natural selection, as having
adaptive significance.
umbilical cord The cord that connects the fetus to the placenta.
unilineal (descent) Tracing descent through either the male or female line.
urethra The tube running from the bladder to the outside of the body. The
urethra transports urine from the bladder to outside the body in both
males and females, and ejaculate in the male.
urethral sponge Sheath of erectile tissue around the urethra that becomes
engorged during sexual excitement and protects the urethra during sexual
activity.
urinary meatus Located between clitoris and introitus in females and the
end of the glans penis in the male; it is the opening in the urethra in both
sexes through which urine passes and ejaculate passes in the male.
urinary stress incontinence (USI) Involuntary leakage of urine.
urinary tract infection (UTI) An infection of the urethra more often found
in women that can be caused by an abrasion of the urethra or infection
by a pathogen.
uterine orgasm According to Singer and Singer (1972: 259–260): “The ‘uter-
ine orgasm’ does not involve any contractions of the orgasmic platform...
this kind of orgasm occurs in coitus alone, and it largely depends upon the
pleasurable effects of uterine displacement.”
uterine tone The muscular strength and integrity of the uterus.
uterus A pear-shaped organ located in the female’s pelvis that is both a pri-
mary and secondary sex organ. The uterus is the site of implantation and
embryo/fetal growth.
vagina Female organ that functions both sexually and reproductively.
vaginal contraceptive ring Flexible ring that releases estrogen and progestin
and is worn for three weeks and removed for one.
Glossary 479
value system System of meanings and beliefs in a culture including art, mu-
sic, rituals, myths, folklore, and cosmology sustains patterning of culture
such as marriage norms, gender roles, courtships, etc.
vas deferens Male reproductive structures that transport the sperm from the
epididymis to the seminal vesicles.
vasectomy Male sterilization procedure where each vas deferens is surgically
blocked to prevent sperm from passing through.
vasocongestion A physical condition occurring during sexual intercourse
when blood vessels in the genitals engorge.
vernix A waxy, protective substance covering the fetus.
viability The ability of the neonate to live.
Victorian era Historical period covering the rule of Queen Victoria of En-
gland (1837–1901). This era saw strict rules in regard to morality and val-
ued the unspoiled or the pristine state. Sexual impulses were associated
with shame and were suppressed or never publicly shared.
visiting husband In polyandrous marriages, the woman does not live with
her husband, but he may visit her for sexual relations.
vulva External sex organs of the female, including the mons, major and mi-
nor lips, clitoris, and opening of the vagina.
vulval orgasm This is the type of orgasm described in Masters and John-
son’s human sexual response cycle. It includes the reduction of the vaginal
opening due to engorgement of the surrounding erectile tissues, with or-
gasm occurring three to twelve contractions at 0.8 second intervals.
Westermarck Effect Theory of the lack of erotic desire that people who are
raised in proximity feel toward one another (i.e., “proximity breeds contempt”).
Western Blot Test A confirmatory HIV antibody test.
window period The time between infection with HIV and when antibodies
to the virus are detectable.
withdrawal Coitus interruptus.
Wolffian Ducts Embryonic structures that develop into male sexual and
reproductive organs if male hormones are present and into part of the
urinary tract system in both males and females.
Wolffian Inhibiting Substance A non-existent substance analogous to MIS.
woman marriage The practice found in some cultures wherein two women
marry. One may become the “social” male and makes arrangements for
the wife to become pregnant by another man.
woman years The number of failures for a given contraceptive method per
100 couples during a year of use called women years because women are
the ones who are impregnated.
World Health Organization (WHO) An international organization located
in Geneva, Switzerland, that addresses global health issues.
xanith A third gender identity found among the Omani in the Middle East.
zygote transplant The implantation of the fertilized egg into a woman’s fal-
lopian tubes.
zygote A fertilized egg.
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Index
AARP 324–326, 328, 339 American Association of Retired Persons

AASECT (American Association see AARP
of Sex Educators, Counselors, and American Association of Sexuality
Therapists) 271 Educators, Counselors and Therapist
Aboriginal Australian 17, 232, 420 see AASECT
abortificant 143, 166–167, 176–179 American College of Obstetricians and
Abramson, A. 9 Gynecologists 408
abstinence 143, 151, 155–157, 178, 181, American Hook Up: The New Culture of
260, 264, 270–273, 277, 279, 404, Sex on Campus 313
410, 415–429 American Medical Association 167,
acculturation 14, 104, 242, 244, 449 191, 408
Acquired Immune Deficiency Syndrome American Psychiatric Association
(AIDS) see sexually transmitted (APA) 117, 301, 353, 366–367
disease American Red Cross 410
Acyclovir (Zovirax) 393 amniocentesis 120–121, 176, 441, 450
Adolescence: An Anthropological Inquiry amnion 190–191, 451
10, 252 amniotic sac 165, 191, 463
Adolescent Family Life Act (ALFA) 272 ampulla 108, 450
adrenal glands 69, 77, 81, 84, 96 analogous 6, 68–70, 72, 73, 78–79,
adultery 57, 252 88–89, 95–96, 100, 102, 108, 112,
affairs 13, 344, 428 119–120, 122, 134, 244, 450
Affordable Care Act and Teen ancestor 17, 51–54, 56–57, 185, 207,
Pregnancy Prevention (TPP) 169, 260 210, 443, 454, 461, 472
age grade 235–236, 449 Anderson, S. and Must, A. 233
age norm 226, 341 androcentric 40, 65, 69, 106–107, 290,
age of majority 275, 440 293, 450, 455
age sets 236, 449 Andro-Gel 337
AI-D see artificial insemination, donors androgen 33–34, 70, 76–77, 80, 85, 93,
AIDS see sexually transmitted disease 96, 114, 136, 303, 307, 352, 372, 450
AIDS Drug Assistance Programs androgen deficiency syndrome,
(ADAPs) 415 female 307
AI-H see artificial insemination husband Androgen Insensitivity Syndrome (AIS)
Alan Guttmacher Institute 154, 169, 33, 136, 450
258–259, 319 androgyny 61, 285, 365, 381, 385,
alcohol 80, 84–85, 92, 93, 96, 97, 387, 450
118–119, 140, 197, 313, 338, 411 andropause 321, 327, 329, 450
alliances 59, 116, 127, 216, 218, androsterone 76, 450
249, 253 androstriol 114
alloparenting 318, 450 anorexia nervosa 100, 451
alyha (male two spirit) 34, 378 “Anthropology and the Abnormal” 6
556 Index
antibody/antibodies 199, 403, 405, 408, bilateral descent (both lines) 59,
415, 450, 461, 179 104–105, 128, 207, 424–425, 429,
Antigen/Antibody Test 405 436–437, 452, 456, 468, 474
antiretroviral therapy/drugs (ARV) bilineal descent 59, 207, 351, 452
390, 396, 398, 402, 404, 413, 415, Billings method 156, 157, 452
416–418, 450, 451, 461 bipedalism 47, 51, 53–55, 66, 212, 441,
anus 86, 87, 92, 105, 213, 393, 470 443, 452
A–200 pyrinate 392 Birdcage, The 359
Arapesh 38–39 birth control 69, 76, 92, 125, 128,
arousal 3, 11, 34, 37–38, 71, 73, 84, 138–164, 166, 171, 175, 177, 180,
91–93, 103, 106, 111, 125, 256, 184, 186, 189, 198, 199, 254, 260,
280, 286–287, 295, 296, 266–270, 300, 330, 441, 449, 452,
301–305, 310, 451, 456, 458, 459, 464, 468, 473, 477, 483, 486; see
474, 475 also contraceptives
ART see Assisted Reproductive Birth Control Guide of the Food and Drug
technology (ART) Administration 143, 152
artificial insemination 58 bisexual 248–249, 253–255, 271, 272,
artificial insemination by Donor 281–282, 343, 348–355, 358, 362,
(AI-D) 120, 122, 130–131, 317, 382, 442; behavior 350, 354; biphobia
441, 451, 476 354; females 343; orientation 350
artificial insemination by husband Blackwell, C., Birnholz, J. and Abbot,
(AI-H) 120, 122, 130–131, 451 C. 316
ARV see antiretroviral therapy/ Blackwood, E. 282, 384
drugs (ARV) Blackwood, E. and Wieringa, S. 29, 352,
ascribed status 428, 451 358, 380, 383–384
Assisted Reproductive Technology blastocyst 167, 180
(ART) 121, 132, 190, 317, 416 blended orgasm 296, 452
A-tent orgasm 296, 450 Blue Collar Marriage 22
azhu huny (friend marriage) 209 Boas, F. 6
Azithromycin 391, 392, 394 Boddy, E. 244
Bolin, A. 30, 374, 375
baby-boomers 324, 326–327 Bolin, A. and Whelehan, P. 30
Baeten, J. et al 443 Borneman 226
Baker, D. and King, S. 220 Boston Women’s Health 335
Baltimore Longitudinal Study of Boswell, J. 349
Aging 328 Boyd, R. and Richerson, J. 27–28
Bancroft, J., Loftus, J. and Long, J. Brandes, S. 322, 343–344
338, 341 Brave New World 122
Barale, M. 31 Breedlove 373
Barash, D. 64–65 broad ligament 106, 108, 134, 451, 467
Barker-Benefield, G. 90, 127 Brokeback Mountain 359
Bartholin’s gland 73, 92, 101, 105 brothel 424, 429
basal body temperature 62, 76, 150, Broude, G. and Greene, S. 13
156, 452 Brown, J. 336
Basson, R. 303–304, 309 Brown, J., Halpern, C. and L’Engle, K. 270
BBT see basal body temperature Brown, J. and Kerns, V. 343
Beach, F. 62 Bruckner, H. 271
Bearman, P. 271 Brunei, Malay 126–127, 171
Benedict, R. 1, 6, 9, 18, 281, 460 BSTc 372–373
Benjamin, H. 371 Burke, Tarana 43
benzathine penicillin 296–297, 392 Burley, N. 63
Bernstein, R. 29 Burnham, D. 39
Besnier, N. 377, 381 Burton, R. and Whiting, J. 238–239
Beyene, Y. 335 Bush, Geoge W. 168, 260, 356, 470
Index 557
C trachomatis bacteria 394 chromosome 31, 33, 48, 58, 121, 371;
caesarean/cesareean section see c-section level 371; selection 58
CAM see complementary and alternative Chuckchee (Russia) 34, 378, 380
medicine Cialis 325–326
Canadian Organization for a the Rights Ciprofloxacin 394
of Prostitutes (CORP) 426 circumcision 85–87, 94, 103–104, 122,
Candida albicans 391 240, 242, 411, 423; female 276, 423
Canela, Brazil 57 Circumcision through Words 245
Caplan and Tripp 304 Civil Rights Act of 1964 (EEOC) 42
Carnaval Brazil 380 clap 392
Carol 359 Clindamycin cream/pills 391
Case of the Female Orgasm, The 65 Clinton, Bill 168, 358
Cassell, C. 60 clitoral hood 73, 100–102, 241, 454, 471
caste 204, 206, 207, 285, 457 clitoral orgasm 289, 293
Castleman’s Great Sex: A Man’s Guide clitoral shaft 73, 454, 471
to the Secret Principles of Total Body clitoridectomy 103–104, 233, 239,
Sex 327 240–241, 454
castrate, castration 82–84, 108, 373, clitoris 70, 71, 73, 85, 101–104,
453, 469 133–135, 158, 239, 241–242, 245,
Castro, San Francisco 350 283, 289, 292, 293, 362, 454, 455,
caul 191, 433 460, 463, 469, 473, 474, 475, 478, 479
Caya Contoured Diaphragm 144 cohabit 248, 360, 442
CC see cerebral cortex coitus 31, 34–35, 64, 143, 181, 220, 247,
CC + (H-P-G axis) 72, 78, 80–81, 93, 252, 257, 284, 286, 288, 291, 294,
95, 122, 453 392, 459, 469, 478
CDC 162, 269, 271, 354, 406, 409 coitus interruptus 156, 178, 186, 454
CD4 cell 403 Columbia University 271
Cefixime 392 Comfort, A. 289
Cefotetan 394 Comfort of Home: Prostitution in Colonial
Cefoxitin 394 Nairobi, The 429
Center for Disease Control and Coming of Age in Samoa 6–7, 8, 142,
Prevention (CDC) see CDC 231, 274
cerebral cortex (CC) 50, 70, 72, 78, 93, community-based organizations (CBO)
95, 451 328, 436, 454
Certriaxone 392 complementary and alternative medicine
cervical cap 145, 158–159, 453 331, 333–334
cervix 70, 110–111, 125, 145, 152, conceive 48, 62–63, 71, 73, 92, 85, 107,
157–158, 164–166, 179, 183, 191, 131–132, 180, 189
294, 295–296, 392, 453, 456, 459, conception 92, 95, 111–113, 117, 120,
460, 464, 467, 469 124–127, 131, 134, 140, 177, 256
Chagnon, N. 184–186 conceptus 428
Chairman Mao 386 Congenital Adrenal Hyperplasia
Chancroid 394 (CAH) 129
Chappel, E. and Coon, C. 237 Continuum Complete Internatonal
childbearing 127, 171, 173, 185, Encyclopedia of Sexuality 254
319, 459 Copper Eskimo, Canada 228–229, 286
Child Maltreatment Survey, The 219 corpora cavernosa 87, 454
chlamydia 109, 390–392 corpus 92, 108–109, 110, 115, 372, 455
Chlamydia trachomatis 391 corpus luteum 115, 455
Chlamydia urealyticum 392 corpus spongiosum 85, 87, 91, 92–93, 455
Chodorow, N. 238–239 Cote, J. 9
chorion 116, 121, 453, 462 courtship 5, 16, 55, 256, 260, 455, 471
chorionic villi sampling (CVS) 120–121, couvade 195, 197, 455
441, 453 Cowper’s gland 23, 92, 105, 455, 471
558 Index
COYOTE (Call Off Your Old Tired double standard 31–32, 59, 105, 119,
Ethics) 426 142, 220, 224–225, 250–252, 256,
Cross, R. 215 276, 300, 413–414, 424–247, 432,
cross-dressers 368, 477 435–438, 474
crura 85, 87, 102, 103, 455 douching 106, 143, 156, 178
C-section 195, 198, 241 doulas 194, 456
Cultural Revolution 209–210 Downie, D. and Hally, D 381
cunnilingus 90, 94, 282, 284, 288, Down’s Syndrome 125
298, 455 Doxycycline 392, 394
curandera 126 Dr. Phil 1, 365
cystitis 103, 455 Dr. Spock Company 223
Dr. Spock’s Baby and Child Care 223
D & C see dilation and curettage drag king 367
D & E see dilation and evacuation drag queen 367
Dalkon Shield 162, 380 dukun 126
Darwin, C. 4, 27 Dunn, M. and Trost, J. 293, 298
Davenport, W. 14, 134, 136, 178, 346 dysmenorrhea 112, 457
David, G. and Cambre, C. 315 dyspareunia 112, 400
Davis, D. 274, 312
Davis, D. and Whitman, R. 11, 16 egg 68, 69, 71, 73, 76–78, 88–89,
Davis et al 136, 303 95–96, 108–109, 111–116, 120–121,
dayas 196–197 125, 129, 156–157, 160–163, 451,
Defense of Marriage Act 356 454, 455, 457, 458, 459, 460, 469,
DeLamater, J. and Sill, M. 235, 323, 471, 479
328–329, 339 egg donor 120
D’Emilio, J. and Freedman, E. 288 ego 208, 215–216, 456
Demographic and Health Survey, Ehrenreich, B. 290
The 205 Ehrenreich, B., Hess, E., and Jacobs,
Depo-Provera 182, 261, 455 G. 293
DES see diethylstilbestrol Eicher, W. et al. 371
Descent of Man and Selection if Relation to ejaculation 90–94, 107, 130–131,
Sex, The 203 156–157, 163, 178, 225, 247, 256,
desogestril 159 292–293, 301, 310, 325, 454, 455
Devereux, G. 179, 182, 380 ejaculatory duct 89–91, 129–457
Devor, H. 372–373 Electra complex 213–214, 457
DHEAS 303 ELISA (enzyme-linked immunosorbent
Diagnostic and Standards Manual of assay) 407, 457
Mental Disorders (DSM) (all editions) Else-Quest, N., Hyde, J. and DeLamater,
117, 301, 302, 303, 304, 307, 308, J. 35
309, 311, 312, 353, 366, 367, 368, Ember, C. and Ember, M. 29
375, 456, 474, 477 embryo 69, 109–111, 116, 120–121, 124,
diethylstilbestrol 98, 372 127, 131, 137, 167, 370, 441, 450,
dilation 164–165, 191, 456 453, 457, 459, 463, 467, 478, 479
dilation and currettage 165, 456 emic 28, 179, 242–243, 245, 279, 322,
dilation and evacuation 165, 456 378, 395, 417, 433, 451
Divale, W. and Harris, M. 184, 185 enanthate (TE) 162
divorce 127–128, 217, 316–319, 342, endemic 116, 127, 253, 395,
360, 398, 442 457, 462
Doctors Without Borders 435 endocrine 3, 33, 70, 76, 330
Doña Bernarda 195–196 endocrine gland 70, 76, 457, 462
donas 196 Endocrine Society 79, 303, 307
“Don’t Ask, Don’t Tell” 358 endocrine system 323, 328
dopamine 303 endogamy 12, 204, 206, 456
dorsal lithotomy position 106, 456 endometriosis 109–112, 129, 457
Index 559
endometrium 71, 110–113, 115–116, Fausto-Sterling, A. 372
131, 457, 466, 467 FDA 144–152, 158–159, 160, 161, 167,
epididymis 81, 86, 87–89, 134, 451, 288, 306, 308, 328, 333, 334, 338
473, 479 Federation of Feminist Women Health
episiotomy/episiotomies 106, 191–193, Centers, The 296
195, 198, 325–327 fellatee 245–246, 495, 463
erection 82, 92–94, 228, 292, 305, 311, fellatio (oral sex) 90, 94, 127, 246–249,
323, 325–327 282, 284, 298, 351, 459
Erickson, M. 219 fellator 245, 247, 248–249, 459
erotogenic zones 93, 212–213, 223, 457 Female Health Company 157
Erythromycin 391–392, 394 Female of the Species 10, 37
Essure System 150 Feminine Mystique, The 290
estradiol 76–77, 114, 159, 160 feminist 30, 119, 135, 152, 234, 281,
estrogen 69–70, 73–74, 76–77, 79, 288, 290, 296, 342, 377
81–84, 93, 95–98, 100, 106, 108, 111, Ferguson, B. 185
114–116, 134, 159, 160–162, 190, Fernea, E. 386
199, 233, 302, 309, 327, 331–333, fertility 61, 63–64, 71, 76, 85, 87,
337–338, 352, 372–373, 458, 459, 105–106, 112, 122–131, 138–141,
460, 461, 462, 469, 474, 478 167, 177–182, 186, 240, 242, 253,
estrogen (ethinyl estradiol) 159, 160 261, 264, 266, 331, 335, 344, 346,
estrus 11, 47, 51, 53–54, 57, 62–66, 68, 383, 389, 452, 459, 476
115, 458 Fertility Awareness Method 156, 459
ethinyl estradoil 160 fertilization 108–109, 111, 115–116,
ethnocentrism 26, 29, 30, 33, 45, 69, 129–131, 139, 156, 160–161,
104, 238, 242, 280, 290, 348, 417, 166, 441
443, 458 fetus 33, 56–58, 71, 98, 103, 106,
etic 28–29, 177, 179, 242–245, 433, 108–110, 120–122, 125, 132, 165,
437, 458 167–168, 175, 180, 188–194, 351,
etilogy 309, 369–370, 372–373, 458 372, 394, 405, 408, 413, 463, 467,
eunuch 83, 382 470, 472, 478, 479
Evans-Pritchard, E. 380, 384 FGM 242–243, 478
evolution 4, 9–11, 14–16, 22, 24–27, 40, Finkelhor, D. 220–221
47–48, 52, 117, 202–203, 215, 350, Filshie Clip 150
411, 421, 440–441, 449, 451, 458, Flagyl 391
462, 469, 475, 476, 478 Flint, A. et al. 335
Evolution of the Human Sexuality, The 64 Florey Adelaide Male Aging Study
excision 102, 104, 241, 458, 478 (FAMAS) 302
exogamy 12, 204, 210, 216, 218, 249, 458 follicles 76, 108, 113–114
extramarital 12–13, 178, 204, 291, 458 follicular phase 76, 95–96, 114, 459
follicular stimulating hormones see FSH
“Fact Sheet: Hot Flashes” 330 Ford, C. and Beach, F. 1, 10–12, 18, 52,
fallopian tubes 73, 89, 98, 106, 108–111, 205, 225, 227–228, 250–252, 265,
113, 121, 124–126, 129, 133–135, 281, 350
150–151, 163; 453, 457, 458, 459, foreplay 10, 52, 282, 284, 286
467, 468, 479 foreskin 73, 85–87, 100, 102, 454, 459,
Falope Ring 147, 150 460, 471, 475
FAM see Fertility Awareness Method Forplay 107
Famciclovir 393 Forty: The Age and the Symbol 343–344
Family and Community Health 243 four genders 34
Farmer, P. 398 Fox, J. 217
Farrell, W. 60 Francoeur, R. 257, 224, 286
Fateful Hoaxing of Margaret Mead: A Frayser, S. 1, 11, 18, 71, 350
Historical Analysis of Her Samoan Freeman, D. 8–9, 16–17
Research, The 8 frenulum (frenum) 87, 459
560 Index
Freud, S. 5, 23, 64, 112, 133, 135, 201, Godziehen-Shedlin, M. 195–196
211–215, 223, 224, 226, 274, 287, Goffman, E. 427
289–290, 320, 352, 450, 464, 465, Goldberg, H. 60, 296–297, 309
468, 469, 470, 472, 473, 477 Goldman, R. and Goldman, J. 225–226
Friday, N. 289 Gombe National Park (Tanzania) 56
Friedan, B. 290–291 gonad/gonads 31, 33, 70, 72, 76, 108,
FSH 73–76, 80, 88, 93, 95, 96, 108, 371, 460, 462, 467, 474
114–116, 459, 462 gonadal dysgenesis 136
fundus 108, 110, 459, 460 gonadal sex 33, 133, 137
gonadatropic releasing hormone see
G see Gonads GnRH
Gagnon, J. 35 gonadotropins 70, 72, 73–74, 76, 80, 96,
Gallup Poll 169, 171 108, 460
gamete 68–69, 112, 130, 460, 476 Gonococcal Infection (Gonorrhea,
gamma benzene hexachloride 392 clap) 392
Garcia, J. 312 gonococcus 392
Gardnerella vaginalis (yeast infection) 391 gonorrhea 109, 145, 182, 390, 392
Gay Rights Movement 349, 357 Goodall, J. 56
Gay, Lesbian, Bisexual, Transgender, and Grafenberg, E. 107, 295–297, 461
Queer Pride Parade 349 Grafenberg spot see G-spot
Gay-Related Immune-deficiency Disease grasping hand 46–47, 50–52, 53, 66, 445
390, 398, 415, 460 Greenberg, D. 349
Gbaya, Africa 104, 242 Greene, M. 253
Gebhard 219 GRID see gay-related immune deficiency
geishas 428 Grimes, D. 176
gender identity 24, 31, 33, 38, 124, Gruenbaum, E. 242–244
132–134, 137, 239, 349, 364–365, G-spot 103, 107, 295–297, 461, 470, 475
370, 373–379, 383–385, 387, 422, 453 G-Spot and Other Recent Discoveries about
gender identity disorder 366–367, Human Sexuality, The 296
373, 371 Guests of the Sheik 386
gender roles 16, 23, 31, 33, 36, 38–39, Guttmacher-Lance Commission 171
55, 71, 78, 95, 122, 128, 133, 137, gynecomastia 84–85, 135, 461
183, 221, 223, 287–288, 319, 340,
357, 364–388, 450, 458, 474, 479 HAART 390, 396, 415, 451, 461
gender transformed status 34, 374, 378 Hammock, G. 20–46
genetic sex 132–134, 137, 453, 460 harem 213–214
genitalia 33, 38, 54, 90, 93, 133, 135, Harris, M. 177
136, 219, 223, 225, 228, 241, 248, Harry Benjamin International Gender
283, 292, 302, 307, 454, 473 Dysphoria Association 367
Gentamicin 394 HBIGDA Standards of Care 367
geriatric sexuality breakdown HCG see human chorionic
syndrome 341 gonadotropin
Gewertz, D. 39 Heino, R., Ellison, N. and Gibbs, J. 315
GID see gender identity disorder Helm, H. et al 314
Gilligan, C. 173 hematocolpos 243
glans 73, 85, 87, 91, 92, 101–103, 240, Henderson, W. 82
242, 454, 459, 461, 471, 475 Hepatitis A virus (HAV) 393
glans clitoris 73, 101, 102, 104, 242, 460 Hepatitis B 85, 393
glans penis 73, 86, 87, 92, 478 Herdt, G. 29, 245–246, 248, 251, 259,
Global Fund to Fight Malaria, 280–282, 387, 474
Tuberculosis and HIV 435 herpes 145, 393
Global Study of Sexual Attitudes and herpes (HSV–2) 390, 393
Behavior Survey, The 305, 324, 342 herpes simplex 2, 390
GnRH 72, 76–77, 80, 95, 114–115, 460 heterosexism 69, 348, 350, 362
Index 561
heterosexuality 32, 69, 87, 90, 92, Human Papilloma Virus (HPV) see HPV
112–114, 117, 120, 124, 132, 140, Human Relations Area Files (HRAF)
162, 164, 197, 226, 247, 248, 250, 10, 184, 227, 250, 281, 345
252, 254–255, 257–258, 281–287, Human Rights Watch 349, 422, 431
291, 299, 313–315, 348, 362, Human Sexual Response Cycle (HSR)
383–384, 409, 461, 476 17, 34, 45, 279, 286–287, 290–292,
Hidden Dimensions, The 28 294, 295, 296, 299, 311–312, 323,
Highly Active Anti-retroviral Therapy 443, 473, 479
see HARRT H-Y antigen 134, 371, 462
hijras (India) 382–383, 423, 461 hymen 104, 462
Hill, W. 380 hypoactive sexual desire disorder
Hite, S. 60, 289 302–303, 327, 337
Hite Report, The 289 hypothalamic release 114
HIV see sexually transmitted disease hypothalamus (H) 71–72, 74–75, 77–78,
HMS Beagle 27 93, 115, 352, 460, 462–467
Hochschild, A. 317 hypothalamus-pituitary-gonad axis see
Hoebel, E. 380–381 H-P-G Axis
holistic 20–21, 182, 184, 286, 327, 337, hysterectomy 112, 122
395, 417–418, 435, 438, 440, 461
hominid 17, 47, 50, 68, 202, 461, 476 ICSH 76–78, 80, 96, 464
homo erectus 17, 51, 65 immune system 399, 402–403, 411, 416,
homoerotic 248–249, 254–255, 277, 281 418, 451, 468, 479
homologous 70, 72–73, 85, 87, 89, 91, Implanon 161, 462
95, 100, 102, 105, 108, 113, 119–120, in-between gender 31
122, 134, 454, 459, 460, 461 incest 5, 12, 30, 179, 171, 201–202, 204,
homone replacement therapy 96, 107, 211–222, 225, 242, 252, 285, 463, 474
306, 321, 331–332, 462 infant 33, 47, 49, 51–58, 64, 66, 67, 134,
homophobia 226, 363, 348–350, 362, 152, 167, 176, 184, 193, 198–199,
400, 423, 436 202, 204, 212, 213, 228, 241, 243,
homo sapiens 138 282, 367, 397, 405, 407, 413, 416,
homosexuality 6, 30, 35, 249, 282, 291, 441, 442, 453, 467
317, 350–351, 359, 362, 442 infanticide 63, 121, 143, 176, 179, 182,
homosocial relations 240, 257 184–186, 294, 460, 463
“hooking up” (hook up) culture 13, infertile 120, 124–125, 127–132, 384,
312–315, 320 390, 391, 478
hot flashes 98, 107, 330–333, 335, infibulation 104, 122, 241, 243, 463, 478
338, 461 In Her Prime: A New View of Middle-
How to Female Ejaculate: Find Your Aged Women 343
G-Spot with Deborah Sundahl 297 Inis Beag, Ireland 14, 322, 331
How to Female Ejaculate for Couples 297 initiation 23, 61, 93, 104, 113, 229, 233,
H-P-G axis hormones 68, 70–72, 74–78, 235–239, 245–249, 304, 435, 429, 463
80, 93, 95, 96, 100, 111, 113, 122, inseminatee/fellator 245, 463
199, 459, 460, 462 inseminator/fellatee 245, 463
HPV 145, 390, 393 insertive anal sex 409; vaginal sex 410
HRAF files 184, 281, 345; see Human “Instruction and Advice for the Young
Relations Area Files (HRAF) Bride on the Conduct and Procedures
Hrdy, S. 64 of the Intimate and Personal
HRT see hormonal replacement therapy Relationship with the Marriage
HSR see Human Sexual Response Cycle State” 32
Hulka Clip 150 international aid organizations 438
human chorionic gonadotropin (HCG) International Center for Research on
116, 462 Women’s Report 253
Human Immunodeficiency Virus (HIV) International Planned Parenthood
see HIV Federation 260
562 Index
intersex 34, 35, 124, 136, 355, 364, 375, 370, 382, 386, 441, 452, 457, 459,
382, 384, 427, 463, 473 464, 475
interstitial cell stimulating hormone kiss (kissing) 246, 255, 257, 283, 324,
see ICSH 352, 393
interstitial cells 77–78, 80–81, Klein, D. 295
88, 464 Klinefelter’s Syndrome (XXY) 124, 134,
introitus 100, 103–106, 107, 191, 451, 137, 464
464, 478 Koch, P. 339–341
in utero 119, 124, 132–133, 137, 193, Komarovsky, M. 22
224, 352, 441, 463, 474 Konker, C. 227
in vitro fertilization 58, 69, 120, 122, Krippendorf’s Tribe 2
130, 441, 462 Kroeber, A. 380
involution 193–194, 464 Kwell (Gamma benzene hexachloride) 392
Irvine, J. 304 Kwoma, New Guinea 227–228
IUD 143, 149, 155, 160–162, 260, K-Y Jelly 107
262, 464
IVF see in vitro fertilization L1 C.trachomatis bacteria 394
L2 C.trachomatis bacteria 394
J 289 L3 C.trachomatis bacteria 394
Jacobs, S. and Roberts, C. 34, 37 labia 157, 241, 245, 292, 295, 454
Jacoby, S. 326 labia majora 73, 87, 100, 101, 104, 241,
Jadelle (levonorgestrel) 161 464, 468
jergunda 137 labia minora 73, 100–104, 134, 241, 468,
Johansson, W., Dynes, W. and 471, 478
Laurietsense, J. 349 Ladas, A., Whipple, B. and Perry, J. 296
Jones, E. 5 Lancaster, R. 181, 266
Jorgenson, Christina (George) 367 Lang, S. 379–380
Journal of the American Medical laparoscope 112, 163, 464
Association 191 late luteal phase disorder see LLPD
Joy of Sex, The 289 Laumann, E. 219, 297–298, 305, 320,
Ju/wasi (! Kung, San, Ju/’hoansi), 342
Kalahari Desert 180–182, 185–186, Laumann, E. Gagnon, J., Michael, R.,
197, 199, 344–345, 449 and Michaels, S. 297
Laumann, E., and Michael, M. 297
Kaas, M. 341 Laumann, E., Palik, A., and Rosen, R.
Kaiser Foundation 269 302–303
Kama Sutra (The Precepts of Pleasure by Laumann, E. and the National Health
Vaatsyaayana), The 284 and Social Life Survey 297–298
Kaplan, H. 287, 294–295 Lawrence & Garner v. State of Texas 30
Kaplan, H. and Owett, T. 307 Lea’s Shield 145, 157–158, 464
Katchadourian, H. and Lunde, D. 21 Leaving Mother Lake: A Girlhood at the
Kelly, G. 229 End of the World 386
Kessler, S. and McKeena, W. 37, 375 LeClerc-Madlala, S. 251
King, B. 157 Lee, C. 344–345
Kinsey, A. 35, 287, 289, 290–291, 293, Lepowsky, M. 40
295, 298, 320, 322, 323, 355 lesbian-gay-bisexual-transgender-queer-
Kinsey, A., Pomeroy, W. and Martin, C. intersex see LGBTQI
225, 256–257, 287, 292 lesbian 9, 20, 120, 123, 254, 258, 271–272,
Kinsey Institute for Research in Sex, 282, 297, 304, 315–317, 341, 343,
Gender and Reproducion 35, 291 348–349, 354, 355, 357–359, 361,
Kinsey Reports 35, 290–291, 464 376–377, 384, 427, 460, 464
kinship 5, 12, 14–15, 16, 59, 126, Lesotho 282
132, 167, 198, 201–203, 209–210, Lesu 228
214, 216, 219, 229, 232, 253, 344, Levine, J. 229
Index 563
Levine, M. and Troider, R. 304 Manfredi-Romanini, M. 372
Levi-Stauss 216 Mangaians (Cook Island) 100, 102, 279,
Levitra 325–326 283–284, 320, 322
Levonorgestrel 160–161, 469 manly-hearted women 359, 378, 385
Levy, R. 381 Manus 227–228
Lexvofloxacin 391 Marquesans (Pacific) 205, 228, 471
leydid cells 78, 81, 88, 465 Marshall, B. and Katz, S. 323
LGBT 254, 288, 355–356, 358; Marshall, D. 283–284, 322
community 358 Marshall, D. and Suggs, R. 350
LGBT, LGBTQI, LFBTQIA 44, 254, Martin, M. and Voorhies, B. 1, 10, 16,
282, 317, 354–356, 358–359, 361, 37, 96
366, 377, 427 master gland 71, 74, 466, 470
LH see luteinizing hormone Masters, W. and Johnson, V. 10, 17, 103,
libidinous functioning 84, 465 287–289, 291–293, 294–295, 298,
libido 71, 77, 80–81, 83–85, 93, 96, 135, 306, 320, 451, 479
162, 212, 213, 327, 327, 332, 338, masturbation 31–32, 35, 41, 82, 85,
465, 473, 477 90, 103, 201, 225, 227, 229, 247,
Lief, H. 303 255–257, 282, 289, 291, 297, 352,
life course 20, 154, 183, 226, 231– 410, 424, 466, 467
323, 234, 297, 300, 321–322, 327, Mathieu, C. 386
344–345 Mathur, S., Greene, M. and Malhotra,
limbic system 73, 78, 93 A. 253
lineage 12, 116, 128, 210, 216; matricentered societies 65, 96, 386, 466
female 205 matrilineal descent societies 207–209,
Linnaean Society of London 27 252, 467
Lish, J. 372 Matzner, A. 381
Liu, P. 162 Mayan, Yucatan, Mexico 126, 195–197,
LLPD 95–96, 115, 117–119, 464 420, 335, 346
LLPD/PMS 95, 115, 117–119 McLennan, J. 4
Lock, M. 335 McLennan, J., Lubbock, J., and
love 24, 26, 36, 183, 184, 209, 212, Morgan, H. 5
221, 224, 226, 256, 276, 284, 300, Mead, M. 1, 6, 9, 16–18, 38–39, 67, 231,
315–316, 348, 354, 360 273–274, 281, 283, 331
“love ‘em and leave ‘em” 57 Meigs, A. and Barlow, K. (2002) 211, 218
LTH 74, 76–78, 95, 109, 190 Melanesia (Pacific Island) 5, 130, 143,
Lubbock, J. 4 156–157, 159, 161–162, 164, 178,
Luker, K. 142 245, 252, 351
lunar woman’s cycle 76, 143 menarche 17, 112, 181, 232–233, 239,
Lunelle 148, 161 248–249, 251, 261, 265, 449, 465, 466
luteal phase 96, 115–116, 117–118, 465 Mendel, G. 27
luteinizing hormone 73–78, 88–93, Menopausal Hormone Treatment
95–96, 108, 114, 116, 352, 462, (MHT) 331–334, 336
464, 465 “Menopause—Another Change
Luzhkov, Y. 349 in Life” 330
Lymphogranuloma Venereum menses 111, 115–116, 327, 466, 476
(LGV) 394 menstruation 33, 81, 94, 96, 100, 109,
111–114, 116–118, 146–147, 152,
Maasai, Kenya 241–243 160, 166, 179, 181, 231, 233–234,
Macassans, Indonesia 17, 420 239–240, 275, 330, 344, 391–392,
machismo/marianisma 59, 116, 400 423, 451, 453, 456, 459, 465, 466,
Mae Enga, New Guinea 116, 130 467, 470, 471, 472, 473
mahu 378, 381, 385, 465 Messenger, J. 14, 322, 331
Malinowski, B. 1, 5–6, 9, 18, 211, methyltestosterone 338
214–215, 281 Meuleman, E. and Van Lankveld, J. 303
564 Index
MHT see Menopausal Hormone National Institute of Aging 328, 331, 332
Treatment National Institute of Health 331, 332, 333
miconazole 391 National Survey of Adolescent Males 264
Micronesia, Pacific Island 143, 156–157, National Survey of Family Growth 141,
159, 160–162, 164, 178, 182, 252, 386 258, 260, 262–263
mifeprex 165–166 National Violence Against Women,
mifepristone (mifeprex) 165–166, 467 The 220
Migeon, D., Rivarola, M. and Forest National Vulvodynia Association,
M. 372 The 309
Miracle, D. and Suggs, A. 10 National Youth Risk Behavior Survey
MIS see Mullerian ducts Mullerian 2007–2017 260
inhibiting substance Nature and Evolution of Female Sexuality,
misoprostol 166 The 64
missionary position 5, 54, 107, 282 Navajo 359, 380, 382, 467
mittelshmerz 115, 462 Nayar 206, 209
Modern Maturity magazine 324 “near man” 137
Money, D. and Ehrhardt, A. 33, 370 Needlman, R. 223, 234, 274
Money, J. and Mathews, D. 372 Neisseria gonorrhoeae 392
Money, J. and Williams, G. 227 “neither man nor woman” 383
monogamy 4, 28, 32, 287, 288, 309, 314, Nelson, J. 222
360, 387, 400, 442, 467 New Guinea 5, 29, 40, 90, 126–127, 130,
mons, mons pubis, mons veneria 73, 100, 210, 227, 239, 245–246, 249, 351, 380
467, 470, 472 New Sex Therapies: Active Treatment of
Montorsi, F. et al. 326 Sexual Dysfunctions 295
mood swings 118, 331–332, 471 New View of Men’s Sexual Problems 301,
Moonlight 359 306–307, 311
Mosuo/Moso, Nari, China 209–210, 387 New View of Women’s and Men’s Sexual
Mother-to-Child Transmission 238, 397, Problems 310–312, 320, 342
398, 401–402, 413, 467 New View of Women’s Sexual Problems
MSM see sex with men 299, 301, 310–311, 317, 337
MTCT see mother to child transmission Newcomer, S. and Udry, J. 257
Mullerian ducts 133–134, 467 Newman, A. and Peterson, P. 219
Mullerian inhibiting substance (MIS) Newton, E. 282
134, 467 NGO see non-governmental
Munroe, R., Whitting, J. and Hally organizations
D. 381 NGU see Nongonococcal urethritis
Murdock, G. P. 12, 13, 206, 216, 462 NIH see National Institute of Health
mutilations 84, 104, 242–244 nongonococcal urethritis (NGU) 392
MVA see vacuum devices non-government organizations 412,
My Secret Garden 289 435, 468
myometrium 110 nonoxcynol-9 158–159
norethindrone 159
nadle 359, 382, 392, 467 norgestimate 159
Namu, Yang Erche 386 Norplant 149, 161, 468
Nanda, S. 379, 376 “not feminine” 238
National Cancer Center 159 “not men” 137, 374, 382
National Center for Complementary and “not women” 374
Alternative Medicine 331, 333 Noyes, R. 92
National Council on Aging 324 nuclear family 5, 12, 204, 217, 229, 316,
National Geographic 69 421, 467
National Health and Social Life Survey Nucleic Acid Test (NAT) 403, 405
297–298, 302 NuvaRing 147–148, 161
National Health Interview Survey, The 354 nystatin 391
Index 565
Obama, Barack 168–170, 260, 272, passage ceremony 209, 236, 469
356, 358 patch, the 147, 155, 160, 163, 260,
Oceanic position 283 261, 469
O’Connor, D. 226 Patient Protection and Affordable Care
OCP (oral contraceptive pill) Act 170, 260
159–60, 469 patilineal descent (societies) 10, 16, 59,
Oedipus 213–214, 468 90, 104–105, 116, 128, 132, 203, 276,
Oedipus complex 5–6, 211, 213, 223, 470, 474
289, 468 patriarchal society 5, 40, 214–215, 221,
Ofloxacin 391–392 244, 251, 329, 343, 413, 469
Ohno, S. 371 patricentered (male centered) culture
On Our Backs 297 104, 399, 429, 437, 470
Oneida Community, New York 92 Patterining of Human Sexuality 11, 13
oophorectiomies 307 Patterns of Culture 6
Oprah 1, 365 Patterns of Sexual Behavior 9, 10, 12, 52
oral herpes 393 Paul, J. 354
OraQuick 405, 408, 409 Pelvic Inflammatory Disesese (PID) 109,
orchidectomy 82, 91, 469 129, 161–162, 391–392, 394
orgasm, orgasms 10–11, 35, 47, 62–65, penetration disorder 302, 309
66, 71, 93–94, 103, 105, 107, 109, penetrative sex 336, 337, 413, 424, 432
111, 135, 225, 241, 243, 256–257, penile-vaginal (p-v) intercourse 3, 71,
284, 293–296, 303, 307, 310, 330, 90, 93, 102–104, 107, 112, 126, 129,
343, 360, 449, 452, 461, 464, 471, 131, 137, 158, 250, 258, 265, 284,
473, 474, 475, 477, 471, 479 288, 322, 325, 335, 418, 431, 433,
OrthoEvra 147, 160 441, 470, 476
os 110, 111, 125, 191, 469 penis 70–73, 82–85, 87, 90–92, 100,
osteroporosis 77, 82, 97–98, 330, 102–103, 106, 133–135, 137, 213,
332–333, 469 223, 227, 255–256, 282–284,
Oswalt, W. 232 291, 305, 325, 382, 392, 410, 451,
ova, ovum 97, 112, 139, 159, 455, 454, 455, 459, 460, 464, 469, 470,
459, 469 473, 478
ovary, ovaries 69–71, 75–96, 100, 108, People Living with HIV/AIDS
110, 111, 113–114, 120, 125, 136, (PLWH/A) 399, 404, 470
149, 156, 307, 330, 468, 469 People of Color 44, 298, 398
Ovcon 159 people with disabilities 44
ovulation 49, 62–63, 66, 77, 96, 98, PEP see Post-Exposure Prophylactics
108, 111, 113–114, 115, 117, 125, PEPFAR 416–417, 437, 470
129–131, 157, 160–161, 181–182, PERFAR see President’s Emergency
199, 266, 452, 453, 462, 465, 469 Plans for AIDS Relief
oxcytocin 64, 191, 469, 470 perineal 62, 91, 106, 191, 309
perineum 87, 105–106, 191, 198, 470
P24 protein 403, 405 permatogenesis 77
Pan American Health Organization 254 Perry J. and Whipple, B. 296–297
pansexual 348, 349, 354 personality-sexual disorders 371
PAP smear see Papanicolaou Smear Pew Research Center 171
Papanicolaou Smear 110, 145, 469 Pfizer 306, 324, 342
ParaGuard 162 pharmaceutical companies 331, 338,
paraurethral glands 107, 110, 469 421, 433
Parker, R. 282, 299 pheromones 62, 72, 78, 117, 470, 475
Partial Birth Abortion Ban 168 phratry 210, 470
participant-observatio 5, 29, 460, 469 PhRMA see pharmaceutical companies
partner(s) 60, 62, 158, 233, 255, 323, Phumaphi, J. 241
337–339, 343 PID see Pelvic Inflammatory Disease
566 Index
pituitary (master gland) (P) 70–72, progestin-only Pill 146, 160, 474
74–78, 88, 95, 113, 190, 191, 466, prolactin 74, 76–78, 372
467, 470, 472 promiscuity 4, 64, 160, 310, 472
placenta 111, 116, 190, 193–194, 453, prostaglandins 109, 117, 165, 466, 472
471, 478 prostate gland 86, 87, 91, 94, 460, 472
Plan B 148, 160, 461 prostatitis 91, 94, 472
Planned Parenthood Federation of prostitution 417, 420, 422–443, 477
America 153, 160, 162, 257, 288, 330 puberty 8, 33, 36, 71–73, 78, 80–81, 83,
plateau (sexual stage) 292, 295 85, 88, 96, 98–100, 113, 125, 132,
PMS see premenstrual syndrome 136, 185, 212–214, 225–226, 229,
polyandrous marriage 206, 479, 471 231–240, 250–251, 265, 290, 292,
polygamy 205, 471 297, 428, 450, 462, 464, 472
polygyny, polygynous societies 58, 116, pubic hair 73, 82, 97, 100, 197, 233,
117, 128, 186, 205, 206, 238, 403, 392, 472
471, 475 pubic lice (crabs) 392, 475
Population Control 139, 162, 177, pubococcygus muscle 103, 296, 472
186, 471 Purdah 386
pornography 24, 327, 410; sites 423–424, p-v intercourse see penile-vaginal (p-v)
427, 436 intercourse
Post-Exposure Prophylactics (PEP) 390,
404, 471 quality of life 61, 325, 339
postmenopause 62, 81, 96, 112, 124, 333, queer 282, 348–349, 355, 357, 460
338–339, 344, 461 Queer as Folks 359
postpartum 139, 178, 181, 183, 195–198, Queer Eye for the Straight Guy 359
248, 387, 423, 456, 471 quickening 167, 190, 472
postpartum depression 158, 199, 447 Qur’an 243
Pre-Exposure Prophylactics (PrEP) 390,
403–404 race (ethinic groups) 155, 171, 233, 254,
premarital sex 249–253, 256, 260, 265, 291, 335, 336, 386, 400
268, 288, 291, 299, 300, 387, 471 Raiders of the Lost Ark 2
prementrual syndrome (PMS) 95–96, Ramey, E. 74
115, 117–119, 124, 464 Ranizini, G. and Lutz, C. 315–316
Prentiff Cap 145 rape 24, 30, 40–43, 84, 110,–171,
prepuce 73, 100–104, 240–241, 454, 571, 220, 416
475 Reagan, Ronald 168, 415;
President’s Emergency Plans for AIDS Reaganesque 272
Relief see PEPFAR Reiss, I. 256, 4-, 451
primary sex characteristics 70–71, 77–78, relatives 8, 11, 49, 50, 54, 65, 105, 202,
80, 85–93, 95, 97, 100–112, 471 205–206, 210–211, 214–216, 220,
primates 26, 47, 49, 50–53, 55, 61, 62, 344, 408, 435, 441, 452, 454, 458, 472
64, 66, 202, 440–441, 470 Renshaw, D. 52
Priscilla, Queen of the Desert 359 reproductive cycle 49, 56–57, 63–67,
Probe 107 88, 105, 109, 117, 131, 287, 329, 354,
procreation 187, 194, 272, 285–286, 300, 441, 472
329, 351, 495 reproductive functions 81, 109, 112,
progesterone 69–74, 76–79, 81, 84, 93, 116, 473
95–97, 100, 108–109, 111, 115–116, reproductive success 49, 56–57, 65, 66,
118, 159, 161–162, 166, 190, 199, 88, 105, 287, 329, 354, 441, 473
327, 330–332, 449, 455, 459, 460, reproductive structures 31, 33, 71,
461, 465, 467, 469, 471, 474 78, 81, 93, 100, 103, 106, 133, 241,
progestin (norethindrone) 159–161, 163, 473, 474
332–333, 372, 462, 468, 469, 471, rete testes 134, 473
478, 484 retrovirus 402, 405, 418, 473
Index 567
rhythm method 76, 143, 150, 156–157, Sex and Temperament in Three Primitive
156, 199, 473 Societies 39
Riportella-Mueller, R. 322 sex cues 72, 81, 97, 100, 117, 474
Rites de Passage (rites of passage) 113, sex drive 71, 81–82, 84, 96, 295, 473
231, 236–240, 245, 268, 273, 275– sex hormones 69–70, 74, 76, 79,
277, 344, 375, 458, 461, 465, 466, 474 80–81, 83–84, 95, 96, 332, 370, 450,
ritual marriage 206, 473 457–458, 460, 474
ritual totem meal 214, 473 Sex Information and Education Council
Ritualized Homosexuality in Melanesia 351 of the United States 271
Robbins, R. 433 Sex in Primitive Societies 6
Roe vs. Wade 167–170, 178 Sex Is Not a Natural Act and Other
root 87, 380, 473 Essays 298
Rosen, R. 303 sex with men 379, 383, 395
Ross, E. and Rapp, R. 39 Sex, Love and Health in America: Private
Choice and Public Policies 297
safe sex 400, 410–411, 473 “Sex, Romance and Relationships:
safer sex 25, 90, 131, 270, 389, 395, AARP Survey of Midlife and Older
402, 409, 413, 417–418, 425, 435, Adults” 324
437–439, 456, 473 sex work 25, 356, 381, 412, 414, 420,
Salem, North Carolina 236 422, 423–438, 474
Sambia 29, 90, 109, 127–129, 130, 137, sexology 2, 6, 20, 22, 40, 284,
231, 240, 277, 282, 251, 386–387 286–298, 398
Sambia: Ritual, Sexuality and Change in Sexual Behavior in the Human Female
Papua New Guiena 245 35, 290
same sex 13, 31, 232, 255–255, 349, Sexual Behavior in the Human Male
356–357, 361–362, 424, 431 35, 390
same sex couples (spouse, partner) 324, sexual double standards see double
355–356 standards
Samoan culture 7, 8, 228, 273–274, sexual intercourse 142, 228, 248,
283–285 252–253, 258, 260, 269, 271, 297,
Sanday, P. 40 308–309, 394
Sartorius, G. 328 sexual desire disorder 1, 302–304, 327,
Scarlet Alliance in Australia 426 337, 474
Schlegel, A. and Barry, H. 10, 240, 250, Sexual Life of North-Western Melanesia:
252, 253 An Ethographic Account of Courtship,
Schneider, D. 182–183 Marriage and Family Life Among the
scripts (scripting) 2, 35, 60, 133, 312, Natives of the Trobriand Islands, The 5
313, 316 sexual orientation 30, 71, 87, 248, 270,
scrotum (scrotal sac) 73, 82, 86, 87–89, 282, 316, 348–349, 350–362, 375,
100, 130, 134, 163, 468, 470, 473, 478 377, 378, 400, 431, 442, 460, 474
Seabrook, J. 430 sexual response cycle 93, 96, 293,
Second Shift, The 317 295–296, 304, 311–312, 330, 341, 479
secondary orgasmic dysfunction 307, 474 Sexual Revolution 61, 246, 287–288,
secondary sex characteristics 71, 77, 300, 304, 310, 319, 326, 359, 364,
81–83, 95, 97–100, 122, 135–136, 365, 475
365, 458, 473 Sexual Risk Advoidance Education
seminal fluid 296 272, 415
seminal vesicles 81, 89, 134, 163, 474 Sexual Risk Continuum 409–410, 475
seminiferous tubles 76, 80, 88, 474, 479 sexual scent (cues) see pheromones
septicemia 242 sexual tourism 376, 422, 430–431,
seven genders 34 437–438, 474
Sex and Repression in Savage Society Sexuality at Midlife and Beyond: 2004
5, 214 Update of Attitudes and Behaviors 339
568 Index
sexually transmitted diseases (includes spermatic cords 73, 87, 88, 89, 455,
AIDS, HIV, STDs, STIs) 35, 61, 80, 473, 477
85, 90, 91, 93, 107, 124, 129, 131, spermatic economy 90, 127, 130, 137,
140, 141–143, 144–154, 157–159, 351, 371, 426, 472, 473
250, 252, 255, 265, 267, spermatogenesis 76–77, 80–82, 88, 93,
269, 270, 271, 276, 281, 358, 95–96, 100, 108, 112–113, 131
360, 389–418, 358, 360, 398, Speroff, L., Glass, R., and Kase, N. 113
402–406, 422, 432–438, 440, Spiro, M. 217
442–443, 450–451, 454, Spock, B. and Needlman, R. 233
460, 461, 462, 465, Spock, Benjamin (Dr.) 201, 223–234,
468, 469, 470, 473, 475 234, 274
Sexual Well Being Global sponge 88, 102, 145, 159, 179, 296,
Survey 343 476, 478
Seyler, L. 372 Standards of Care for Gender Identity
shaft 73, 85, 87, 100–104, 240, 454, 455, Disorders 367
471, 475 Starka, L., Sipova, I. and Hynie, J. 371
Shankman, P. 9 START 405
Shepher 215, 217 “Stepford Wife” 331
Sherfey, E. 64 steroids 76, 85, 98, 136, 162, 309
SIECUS see Sex Information and Stewart, E. 280–281, 380
Education Council of the United STI see sexually transmitted diseases
States STI/HIV see sexually transmitted
Silber, S. 84 diseases
Silphium 179 stigma 315, 341, 362, 390, 396, 400–401,
Simons, J. and Carey, M. 303 405–406, 414, 415, 417–418, 425–427,
Singer, M. 103 430, 432, 434–435
Singer, J. and Singer, I. 287, 294–295, Stoller, R. 370
302, 320, 478 Stonewall riots 357
Sittitrai 255 straight/straights 317, 349, 353–355,
Skene’s glands 107 357, 359
smegma 87, 102 Strategic Timing of Anti-Retroviral
Smythers, R. 32 Treatment see START
social identity 211, 249, 367–368, 374, Sundahl, D. 297
376, 377 Supermale Syndrome (XYY)
Social Organization of Sexuality: 134–137, 476
Sexual Practices in the United States, “surivival of the fit” 27
The 297 sweatshop 421, 422, 431, 432, 476, 477
Social Structure 12 SWGS see Sexual Well Being Global
“softman” 378 Survey
Sommerville, C. 212 Symons, D. 63–65
Sonefield, A. 175 syphilis 389, 390, 392
sororal polygyny 205, 475
“space and time” 440 Tan, R. and Culbertson, J. 328
spectinomycin 392 Tanner, D. 60
Speilberg, S. 2 Tantras, Tantric 93, 279, 285–286, 320, 463
sperm 56, 60, 69, 71, 73, 75–77, 80, 82, Teen Pregnancy Prevention (TPP)
85, 88–92, 100, 106–107, 111–113, 260, 272
124–125, 129–131, 136, 139, 146, Temporary Assistance to Needy Families
151, 157–158, 161, 162–173, 451, (TANF) 319
453, 454, 456, 457, 460, 462, 465, Terconazole 391
466, 470, 479 testes 34, 69–71, 73–74, 76, 78, 81, 87,
sperm banks 58, 69, 120, 441, 479 108, 113, 134, 136, 292, 328, 371, 477
Index 569
testicles 76, 80–83, 87–89, 91, 134–135, Trump, Donald 170, 175, 288, 434
190, 382, 391–392, 453, 455, 473, Turner, V. 31, 237
476, 477 Turner’s Syndrome (X/XO) 124,
testicular cancer 82, 88 134–136, 137, 478
testicular self-exam (TSE) 88 two genders 34, 375
Testim 337 two-spirit gender 379
testis 86 two spirits 34, 380, 400
testosterone 23, 33, 69–71, 74–75, Tylor, E. B 27, 216
77–79, 80, 81–84, 88, 96, 119, Type I see excision
134–136, 162–163, 295, 303, 306–308, Type II 478
327, 330, 337–338, 352, 371, 449, 450, Type III see infibulation
460, 462, 464, 465, 469, 473, 477 Type IV see FGM
testosterone deficiency syndromes 337
testosterone replacement therapies umbilical cord 190, 193–194
307–337 unisex 287
Tetracycline 392 United Nations 104, 139, 153–154,
third and more gender 374 177–178
‘third gender’ 351, 374, 461, 467, 479 United States Congressional Acts 204,
third-sex 350 206, 215–216
Three Essays on the Theory of Sexuality United States Constitution 175, 356
212, 289 United States Food and Drug
Tiefer, L. 298–299, 301, 306–307, Administration see FDA
310–311, 320, 323, 326, 331 United States Supreme Court 1, 30,
“time and space” 31–32, 49, 68, 126, 167–178, 353, 356
177, 249 University of Chicago 297
Tinidazole 391 University of Indiana 291
Title IX 42 University of Minnesota 254
Title VII 42 urethra 73, 85, 90–93, 101, 103, 296,
Title X gag rule 170 306, 391, 455, 457, 469, 471, 472,
Tiwi, Australia 112, 126–127, 132, 475, 478
205, 249 urinary meatus 73, 85, 91–93, 103, 478
tonic, tonicity 72, 74, 79, 80–81, 93, 95, urinary stress incontinence (USI)
112, 122 107, 478
“Too Young to Wed: The Lives,Rights urinary tract infections 103, 144, 146,
and Health of Young Married 243, 478
Girls" 253 uterine orgasm 294, 452, 475
Totem and Tabu 213 uterine tone 71, 77, 78, 95, 108, 465
totem animal 214, 473, 477 uterine walls 165
Towle, E. and Morgan, L. 379–380 uterus 33, 64, 71, 98, 108–112, 117,
toxic shock syndrome 144–145, 158 121, 125, 127, 134–135, 149, 158,
transformed gender 179, 383 160–162, 164–166, 179, 182, 190,
transgender 26, 272, 282, 335–349, 355, 194, 199, 292, 296, 332, 450, 453,
358, 361, 364, 367–370, 373–374, 377, 455, 456, 459, 460, 464, 465, 466,
381, 387–388, 424, 247, 459, 460, 477 467, 479, 472, 477, 478
transgender syndrome 375 UTI see urinary tract infections
transsexual FTM (female to male) 369,
379, 371–374, 377 Vaatsyaayana 284
transvestite 365, 367–368, 371, 478 vaccine 390, 393, 402
Travels in the Skin Trade 430 vacuum devices 306, 326
Treponema pladdium bacteria 392 Vadenahl 325
Trichomoniasis 391–392 vagina/vaginal 63, 71, 93, 97, 100–107,
True Love Waits 270–271 108, 110–113, 125, 129, 133, 134, 145,
570 Index
157–158, 163, 165, 191, 229, 245, 258, Warrior Mask 244
265, 282, 288–289, 292–293, 295–296, Webster vs. Reproductive Health
299, 308, 309, 321, 325, 330, 335, 337, Services 168
339, 341, 343, 352, 391–393, 401, Weinstein, Harvey 43
404, 410, 418, 432–433, 441, 443, 449, Weiss, D. 226, 377
451–452, 455, 457, 459, 460, 461, 462, Westermarck, E. 217, 281, 380
463, 467, 472, 476, 477, 478, 479 Westermarck effect 217–218, 479
vaginal contraceptive ring 146, 161, 478 Western Blot Test 407, 479
vaginal intercourse 3, 93, 102–103, Wester Uttat Parades 345
104, 112, 126, 129, 158–159, Weston, K. 282
250, 257–258, 282, 284, 288, 295, wet dreams 113, 247, 248
299, 322, 325, 352, 418, 441, 450, Whelehan, P. 30, 118, 222, 386, 427
470, 476 Whipple, B. and Perry, B. 295–297, 320
vaginismus 308–309 White, L. 216
vaginoplasty 245 White, Ryan 415
Van Gennep, A. 236–237, 465 WHO 104, 158–159, 162, 241, 242, 243,
Vance, C. 352, 359 252, 303, 319, 401, 435, 443, 474
Vance, C. and Pollis, C. 281 Wierman, T. 303
Varieties of Sexual Experience 11 Wikan, U. 381
Vasclip 163 Will and Grace 359
vas deferens 73, 88–89, 108, 113, 130, Williams, W. 29, 282, 350, 381–382
133–134, 163, 457, 459, 476, 479 Wilson, E. and Koo, H. 270
vasectomy 89, 163, 479 Wilson, R. 331
vasocongestion 64, 292, 479 Winn, R. and Newton, N. 345
Viagra 69, 306, 308, 310, 311, 325–327, Wolf, A. 40, 217
337, 342 Wolffian ducts 133–137, 473, 479
victims 30, 43–44, 218, 222, Wolffian inhibiting substance 134, 479
425–426, 432 woman marriage 206, 383–384, 479
Vilet, E. 330 woman year 138, 140, 186, 479
Village, New York 350, 357 womb 40, 109, 112, 223, 457
Viral Hepatitis B 393 Women’s Health Initiative (WHI)
Viral Herpes 393 332, 334
virginity 102, 104–105, 123, 203, 243, Women’s Health Initiative Study 107
251, 258, 270, 271, 277, 288 Women’s Health Network 338
vision quest 236, 275 Women’s Movement 288, 298, 300
visiting husbands 206, 451 World Bank 421–422
Vrangalova, Z. 314 World Health Organization see WHO
vulva 90, 100–102, 241, 282, 294, 309, World Health Organization
391, 479 International Classification of
vulval orgasm 294, 479 Diseases 303
vulvodynia 309 World of Human Sexuality: Behaviors,
Customs and Beliefs 9, 10
Wade, L. 314 World Professional Association for
Walker, A. 244 Transgender Health (WPATH) 367
”walking back and forth” 209 Worlds of Pain 22
walking marriage 209, 386 WPATH see World Professional
Wallace, R. 27 Association for Trangender
Walley, C. 242 Health
Walter 218
Ward, M. 221, 330, 387 X and Y chromosomes 121
Ward, M. and Edelstein, M. 41, 173, X chromonsome 134–136, 352
176–179, 240, 246 xanith 381, 385, 479
Index 571
XO female 135 YO male 134
XX chromosome 133, 453 Youth Risk Behavior Survey
XX pairing 132–133 254, 259
XY chromosome 34, 126, 132–133,
137, 453 Zabarma and Haus 244
XY pairing 132–133 Zambia 435
XYY see Supermale Syndrome Zaviacic 296
Zhou, J. 373
Yale University 271 Zilbergeld, B. 60
Yapese (Yap), Caroline Island, Zovirax 393
Micronesia 180, 182–184, 186, zygote 69
228, 265 zygote transplant 69, 479

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“An awesome examination of human sexuality, encompassing biological,

social, psychological, cultural, and global perspectives. The book’s compre-

This groundbreaking second edition of Human Sexuality continues its broad

• pregnancy and childbirth as a bio-cultural experience

Patricia Whelehan, PhD, CST, CAC-CA, NY, is a Professor Emerita from

Anne Bolin, Patricia Whelehan,

ISBN: 978-0-367–21979-6 (hbk)

List of Illustrations xiii

2 Biological, Psychological, and Cultural Approaches 20

3 The Evolutionary History of Human Sexuality 47

4 Introduction to the Hormonal Basis of Modern

5 Modern Human Male Anatomy and Physiology 80

6 Modern Human Female Anatomy and Physiology 95

7 Fertility, Conception, and Sexual Differentiation 124

9 Pregnancy and Childbirth 188

10 Sexuality through the Life Stages, Part I: Early Childhood

11 Sexuality through the Life Stages, Part II: Puberty and

13 Sexuality through the Life Stages, Part IV: Sexuality

14 Sexual Identities, Preferences, and Behaviors 348

15 Sex, Sexuality, and Gender 364

16 Sexual Health: HIV, AIDS, and Sexually

17 Global Aspects of Sex and Sexuality 420

1.1 The individual in society 3

4.1 Comparative anatomy 73

8.1 Birth control methods guide 144

Anne Bolin is an Emerita Professor of Anthropology

Katja Antoine received her PhD in Anthropology from

Georgina S. Hammock is a social psychologist who specializes in the study of

This preface is a welcome to all our potential readers—students, professors,

In this second edition of Human Sexuality: Biological, Psychological and Cultural

I, Katja Antoine, want to express my heartfelt gratitude to Muriel Vernon

The Anthropological Perspective

Sex as Biology, Psychology, and Culture

Genetics Individual Culture

Figure 1.1 The individual in society.

a behavior that involves a choreography of endocrine functions, muscles, and

Anthropological Perspectives on Human Sexuality

In Coming of Age in Samoa, her commentary addressed female adolescence

defers marriage through as many years of casual love-making as possible…

• A dearth of deep feeling between relatives and peers.

[Margaret Mead and Ruth Benedict’s] view of culture as a pattern or config-

Although the approaches of Malinowski, Benedict, and Mead contributed to

Sexual unions without economic co-operation are common, and there

The Patterning of Human Sexuality: The Biological,

Ideology THE ROOF

Adaptations to the environment—how

Figure 1.2 Culture as architecture.

The indigenous Australian people of Arnhem Land had a long history

Human behavior is an incredibly complicated phenomenon. Indeed, it is argu-

Anthropological Perspectives in Contrast

To reduce human sexuality to an instinct to reproduce ignores the importance

The Culture Concept

• Culture is shared in that it is composed of a group of people who experi-

What sort of theory of human values can be devised which encompasses

Definitions of Human Sexuality

Time and Space

Biological Definitions and Dimensions

Behavioral, Cognitive, and Affective Definitions and Dimensions

Socio-Cultural Definitions and Dimensions

Sex, Gender, Masculinity, and Femininity